531774 research-article2014
HEBXXX10.1177/1090198114531774Health Education & BehaviorStrunk et al.
Article
Effectiveness of the Surviving the Teens® Suicide Prevention and Depression Awareness Program: An Impact Evaluation Utilizing a Comparison Group
Health Education & Behavior 2014, Vol. 41(6) 605–613 © 2014 Society for Public Health Education Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1090198114531774 heb.sagepub.com
Catherine M. Strunk, MSN, RN1, Keith A. King, PhD, MCHES2, Rebecca A. Vidourek, PhD, CHES2, and Michael T. Sorter, MD1
Abstract Youth suicide is a serious public health issue in the United States. It is currently the third leading cause of death for youth aged 10 to 19. School-based prevention programs may be an effective method of educating youth and enhancing their help-seeking. Most school-based suicide prevention programs have not been rigorously evaluated for their effectiveness. This evaluation employs a comparison group to measure whether program group participants differed significantly from comparison group participants on pretest–posttest measures while assessing the immediate impact of the Surviving the Teens® Suicide Prevention and Depression Awareness Program. Findings indicate several positive outcomes in program group students’ suicide and depression knowledge, attitudes, confidence, and behavioral intentions compared with the comparison group. Suicide prevention specialists and prevention planners may benefit from study findings. Keywords adolescence, injury prevention, safety, school-based mental health, social cognitive theory Youth suicide in the United States has been a serious public health issue for the past several decades (U.S. Department of Health & Human Services, 1999). It is currently the third leading cause of death for youth aged 10 to 19 years (Centers for Disease Control and Prevention [CDC], 2013a). Although the suicide rates for this age group steadily declined from 2004 to 2007, these rates have increased by nearly 16.5% (3.77-4.30 per 100,000) from 2007 to 2010 (CDC, 2013b). The largest increases were for youth aged 10 to 14. The suicide rate increased by 50% (0.86-1.29 per 100,000) for this age group from 2007 to 2010. For youths aged 15 to 19, the suicide rate increased by approximately 12.2% (6.71-7.53 per 100,000) during this same timeframe. In 2010, there were 1,926 youths aged 10 to 19 years who died from suicide. Unfortunately, for every youth suicide there are between 100 and 200 suicide attempts (American Association of Suicidology, 2008). The economic cost of suicide and suicide attempts in the United States is estimated to be $42 billion annually (American Foundation for Suicide Prevention, 2013a). Risk factors for suicide are numerous and exist on multiple levels. On a personal level, greater than 90% of suicidal adolescents have a diagnosable mental health disorder (Bridge, Goldstein, & Brent, 2006). On the family level,
adolescents experiencing abuse, dealing with the loss of a parent, and lack of family cohesion increase the risk for suicide (Hawton & James, 2005; C. A. King & Merchant, 2008; O’Donnell, Stueve, Wardlaw, & O’Donnell, 2003). In the school setting, social isolation, peer victimization, and exposure to bullying are associated with depression and suicide (Fergusson, Woodward, & Horwood, 2000; Gould, Fisher, Parides, Flory, & Shaffer, 1996; La Greca & Harrison, 2005; O’Brennan, Bradshaw, & Sawyer, 2009). Reducing risk factors is one method many programs address in the prevention of suicidal behavior among adolescents. Fortunately, students who are suicidal tend to show verbal, behavioral, and environmental warning signs (K. A. King, 2006; Rudd et al., 2006). Verbal warning signs include statements such as “I am going to kill myself,” “I want to die,” and “Everyone would be better off if I am dead” 1
Cincinnati Children’s Medical Health Center, Cincinnati, OH, USA University of Cincinnati, Cincinnati, OH, USA
2
Corresponding Author: Catherine M. Strunk, Division of Child and Adolescent Psychiatry, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, M.L. 3014, Cincinnati, OH 45229, USA. Email: [email protected]
Downloaded from heb.sagepub.com at WEST VIRGINA UNIV on May 5, 2015
606
Health Education & Behavior 41(6)
(K. A. King, 2006). Regarding behavior, warning signs include changes in school performance, changes in weight, loss of interest in once enjoyable activities, and social isolation. Environmental warning signs include a previous suicide attempt, a recent suicide attempt, or certain life stressors such as a breakup or sudden loss. Such warning signs can be recognized by other individuals; thus, it is imperative for adolescents to properly identify warning signs and seek help appropriately. Clearly, increased efforts are needed to prevent youth suicide in our nation. The Surgeon General’s Call to Action to Prevent Suicide (U.S. Department of Health & Human Services, 1999) recognizes this urgent need and offers a framework for suicide prevention that includes a number of recommendations, such as developing and implementing safe and effective school-based suicide prevention programs that “address adolescent distress, provide crisis intervention and incorporate peer support for seeking help” (U.S. Department of Health & Human Services, 1999, p. 7). This document has prompted communities across the nation to develop and implement school-based suicide prevention programs. Many of these programs are universal (Robinson et al., 2013) in nature whereby an entire population is targeted, such as youths between the ages of 12 and 18, with the overall goal of reducing risk factors or enhancing protective factors among these youths. Indicated programs, on the other hand, are designed for at-risk teens who exhibit suicide risk factors or warning signs, such as frequent suicide ideation, a previous suicide attempt, depression, or substance abuse. Unfortunately, few of these programs have been rigorously evaluated (Katz et al., 2013; Robinson et al., 2013), which makes it difficult to determine whether or not identified results are because of a program effect versus a cohort or school effect. Although many programs show a positive impact on knowledge and attitudes about depression and suicide (Miller, Eckert, & Mazza, 2009; Portzky & Van Heeringen, 2006; Robinson et al., 2013), few have shown a positive impact on help-seeking behaviors (Aseltine, James, Schilling, & Glanovsky, 2007; Ciffone, 2007; K. A. King, Strunk, & Sorter, 2011; Robinson et al., 2013). This is significant because a lack of help-seeking among youth can lead to suicide (Pagura, Fotti, Katz, & Sareen, 2009). Therefore, the purpose of this evaluation was to assess the impact on students’ help-seeking behaviors as well as the overall effectiveness of the Surviving the Teens® Suicide Prevention and Depression Awareness Program while employing a comparison group to measure whether program group participants differed significantly from comparison group participants on pretest–posttest measures.
Program Description The Surviving the Teens® Depression Awareness and Suicide Prevention Program was developed by Catherine Strunk, MSN, RN, and is offered by the Division of Psychiatry at
Cincinnati Children’s Hospital Medical Center. It is delivered in health classes in four 50-minute sessions over 4 consecutive days. The two major risk factors for suicide, depression and substance abuse (National Institute of Mental Health, 2012), are discussed in great detail throughout the program. Other mental disorders, such as bipolar disorder and schizophrenia, are also discussed. Additionally, students are taught risk factors for depression related to medical illness, family stressors, self-esteem, sexual orientation, peer/ social stressors, trauma/violence, and grief/loss and adaptive ways of coping with these stressors. Students are shown how to recognize signs of depression, suicide, and substance abuse through true stories of other teens who have dealt with these issues. Students are also taught ways to connect and better communicate with family members, anger management, and conflict resolution skills. The Surviving the Teens® program is based on the selfefficacy model of social cognitive theory (Bandura, 1998), which posits that self-efficacy beliefs are major determinants in regulating behavior and are needed to enact change. According to this model, self-efficacy beliefs can be developed in four ways, which are through mastery experiences, vicarious experiences, social persuasion, and reducing stress reactions. The Surviving the Teens® program utilizes three of these to enhance self-efficacy: vicarious experiences, social persuasion, and reducing stress reactions. Vicarious experiences are provided through social models, such as other teens who have experienced depression and successfully asked for help by taking Steps to LAST®. Social persuasion is used by the program’s educator when encouraging students to take Steps to LAST® to help oneself or to help a troubled friend when they or their friends are feeling troubled, depressed, and/or suicidal. Students are taught to manage their emotions and stress reactions through problem solving, cognitive restructuring, and use of relaxation techniques. Both sets of Steps to LAST® are behaviorally based to enhance self-efficacy. Since the Surviving the Teens® program is a 4-day program, however, students have insufficient time to develop mastery over the skills of applying Steps to LAST® in a variety of real-life situations. Nevertheless, students are provided opportunities to practice these skills through several role-play scenarios over 2 days of the program. Although the Surviving the Teens® program is universal in nature, it does target teens at-risk for suicide within the curriculum and offers tools these teens can use to help themselves in the present or in the future when dealing with depression or suicide ideation. Some school-based programs incorporate a screening tool to target teens who are at risk for suicide (Aseltine et al., 2007; Robinson et al., 2009; Waldvogel, Reuter, & Oberg, 2008). However, this approach only identifies those teens who are at current risk. Unfortunately, some teens may screen at a very low risk level at one point in time, but may quickly advance to a higher risk level at a later time (Ciffone, 2007). Therefore, the Surviving
Downloaded from heb.sagepub.com at WEST VIRGINA UNIV on May 5, 2015
607
Strunk et al. the Teens® program not only encourages teens’ seeking help for their at-risk peers but also for themselves when feeling depressed or suicidal through Steps to LAST®. These steps can be easily compared with the Heimlich maneuver since they can be used on oneself as well as someone else in crisis. These steps also employ “LAST” as an easy to remember mnemonic since it is synonymous to “survive,” which is associated with the name of the program. This mnemonic facilitates students’ remembering each step to take to help themselves or their troubled peers. For instance, Steps to LAST® to help oneself refers to (a) Let someone know what is troubling you, (b) Ask for and accept others’ support, (c) Share your feelings, and (d) Tell an adult who can help. Steps to LAST® to help a troubled teen refers to (a) Listen and look for signs of depression and/or suicide, (b) Ask specific questions about suicide, (c) Show support, and (d) Tell an adult who can help. These steps complement each other and work best when used in conjunction with one another. Students participating in the program are given cards that outline both Steps to LAST®, identify referral sources, and give the address for the program website. More details about this program and Steps to LAST® can be found on the Cincinnati Children’s website at www.cincinnatichildrens.org/surviving-teens. Some overarching goals of the program include (a) increase help-seeking behaviors among troubled youth and their peers; (b) increase family and school connectedness; (c) decrease suicidal and other risk-taking behaviors, such as illicit drug and alcohol use; and (d) improve students’ coping skills.
Method Participants Participants of this evaluation were high school health class students in Grades 9 through 12 in Greater Cincinnati area schools. Program group participants were from nine high schools who received the Surviving the Teens® Suicide Prevention and Depression Awareness Program as well as a pretest and posttest survey during their scheduled fall semester health class in 2008/2009 school year. Comparison group participants were in the same grade level in five of the same schools as program group participants, but did not receive the program until after their completing pretest and posttest surveys during their scheduled spring semester health class in 2008/2009 school year. These schools were primarily located in middle-class, suburban communities in three counties in Ohio.
Procedures Principals and health class teachers in the schools where the Surviving the Teens® was being presented were invited to participate in this impact evaluation. Participation in the program and evaluation was completely voluntary. No parents
or students refused to participate in the program and comparison group evaluations. Parents were provided an informational letter that discussed the project purpose, voluntary nature of the surveys, and potential risks and benefits. Informed consent was obtained from parents and school principals for students’ participation in this evaluation. Assent was given by the teenagers who filled out the questionnaires. Students were encouraged to answer all questions, but they were told they could skip any questions that made them feel uncomfortable in answering. Although a small percentage of students were absent for the posttest evaluation, greater than 95% of students were in each class that participated in the study. This evaluation was exempt by the institutional review board (IRB) at a Midwestern hospital. The same presenter, a mental health professional, delivered the program to participants to ensure intervention fidelity. Teachers were given written and verbal instructions by the program coordinator about administration procedures for the pretests surveys. These surveys were administered to program group participants 1 day prior to program delivery. Pretest surveys were administered to comparison group participants 4 days prior to program delivery. Posttests were administered to program group participants immediately after the program (4 days after pretest) by the program coordinator. Posttests were administered to comparison group participants by the program coordinator 4 days after the pretest and immediately before delivery of the program. All surveys were numerically coded to identify each student and school. The program coordinator reviewed the completed surveys before the end of the school day to identify any students who reported being currently suicidal. The school principal, school counselor, and parents/legal guardians were informed of those students with current suicide ideation and these students were assessed by the counselors for immediate suicide risk. If any students disclosed a clear suicide plan or expressed feeling unsafe regarding self-harm, then parents were directed to take them to a local pediatric hospital emergency room. If no suicide plan or immediate plans of self-harm were determined, then these students were referred to mental health professionals within the community. All responses were kept confidential. The program coordinator shredded and destroyed the school code list and student identifiers before transferring the surveys to the program evaluator, making all saved data anonymous.
Survey Development and Testing The survey instrument was developed based on a comprehensive review of the literature and other validated surveys developed and used by Keith King, PhD, MCHES. The following survey sections were used in this program evaluation: Section 1, Perceived Confidence in Helping a Suicidal Friend (5 items); Section 2, Perceived Importance in Knowing Suicidal Warning Signs and Steps to Take with Suicidal Friends (3 items); Section 3, Intention to Help Self or Friends
Downloaded from heb.sagepub.com at WEST VIRGINA UNIV on May 5, 2015
608
Health Education & Behavior 41(6)
if Suicidal (4 items); Section 4, Stigma Related to Suicide, Depression, and Counseling for Mental Health Issues (5 items); Section 5, Perceived Confidence in Handling and Talking about Problems (4 items); Section 6, Self-Esteem (5 items); Section 7, Frequency in Talking to Important Others about Problems (8 items); Section 8, Frequency in Ineffectively Handling Problems (3 items); Section 9, Frequency in Intending to Effectively Handle Problems (3 items); Section 10, Knowledge of Depression Risk Factors (12 items); Section 11, Knowledge of Suicide Risk Factors (11 items); Section 12, Knowledge of Suicide Warning Signs (15 items); and Section 13, Knowledge of Suicide Myths and Facts (10 items). Sections 1 to 6 requested students to rate how strongly they agreed or disagreed with each item via a 5-point Likerttype scale (1 =strongly disagree; 5 =strongly agree). An example of these items was the following: “Please check how strongly you agree or disagree with the following item: I feel confident that I can recognize a friend who is suicidal.” Sections 7 to 9 requested students to rate how frequently they engaged in each behavioral item via a 5-point scale (1 = never [0% of the time]; 2 = rarely [1% to 24% of the time]; 3 = sometimes [25% to 75% of the time]; 4 = most times [76% to 99% of the time]; 5 = always [100% of the time]). An example of these items was the following: “How often do you talk to your parent/guardians about problems you have at school?” Sections 10 to 12 requested students to check the appropriate boxes for each question. An example of these items was the following: “Check the boxes that you think increase the chances for a teen to attempt suicide: __Having a previous suicide attempt.” Section 13 requested students to check either true or false for each statement. An example of these items was the following: “Most teen suicides occur without any warning signs. __True __ False.” Face and content validity of the survey instrument were established by distributing the survey to a panel of experts for review. Suggested revisions were incorporated into the final instrument. Stability reliability of the survey was established by distributing the survey to a convenience sample of students on two separate occasions, 7 days apart. Pearson correlation coefficients were greater than .74 on all parametric subscales. Internal consistency reliability was established for parametric subscales and yielded Cronbach αs >.80.
Data Analysis Data analysis was conducted via SPSS (Statistical Package for the Social Sciences), Version 21.0. Frequency distributions, means, standard deviations, and ranges were used to describe students’ background characteristics. A series of F tests were conducted to assess potential differences in the selected dependent variables (e.g., suicide-related perceptions, helping-seeking intentions, self-esteem, frequency in communicating about problems and handling problems, and knowledge) between the program group and control group participants. More specifically, these F tests were performed
Table 1. Demographic and Background Characteristics of Respondents. Program Group Item Gender Male Female Grade 9th 10th 11th 12th Age 13 years old 14 years old 15 years old 16 years old 17 years old 18 years old Race/ethnicity American Indian African American Asian Hawaiian/Pacific Islander Hispanic/Latino White Multiracial Other
Control Group
n
%
n
%
424 542
43.9 56.1
286 280
50.5 49.5
701 233 26 14
71.9 23.9 2.7 1.5
488 58 21 2
85.6 10.2 3.7 0.4
3 368 440 137 20 4
0.3 37.9 45.3 14.1 2.1 0.4
1 192 285 78 12 1
0.2 33.7 50.1 13.7 2.1 0.2
21 40 16 4 23 822 36 5
2.2 4.1 1.7 0.4 2.4 85.0 3.7 0.5
9 24 5 0 15 474 36 4
1.6 4.2 0.9 0.0 2.6 83.6 6.3 0.7
Note. Percentages denote valid percentages; missing values excluded.
to evaluate the overall effectiveness of the Surviving the Teens® Suicide Prevention and Depression Awareness Program. Missing data were excluded from analyses. The alpha level of significant was set at .05. At baseline, analyses were conducted to identify any significant differences between the program group and comparison group. Results from these analyses revealed no significant differences between the groups based on demographic variables (sex, age, grade, family structure, grades received in past 12 months) as well as dependent variables (suicide-related perceptions, helping-seeking intentions, self-esteem, frequency in communicating about problems and handling problems, and knowledge). Therefore, the groups were deemed equivalent and no covariates were used in subsequent analyses.
Results Demographics A total of 966 students participated in the program group whereas 581 students participated in the control group. Pretest–posttest matches were obtained for students in each group. In the program group, slightly more males (56.1%) than females (49.5%) participated (Table 1). In the control
Downloaded from heb.sagepub.com at WEST VIRGINA UNIV on May 5, 2015
609
Strunk et al. Table 2. Suicide-Related Perceptions, Help-Seeking Intentions, and Self-Esteem Based on Group. Program Group Item Confidence in helping a suicidal friend Perceived importance in knowing suicidal warning signs and steps to take with suicidal friends Intention to help self or friends if suicidal Stigma related to suicide, depression, and counseling for mental health issues Confidence in handling and talking about problems Self-esteem
Control Group
Pretest, M (SD) Posttest, M (SD) Pretest, M (SD) Posttest, M (SD)
F
p
η2
18.75 (3.344) 13.29 (2.030)
21.09 (3.152) 13.63 (1.790)
19.08 (3.377) 12.83 (2.274)
19.55 (3.325) 12.61 (2.177)
124.409
HEBXXX10.1177/1090198114531774Health Education & BehaviorStrunk et al.
Article
Effectiveness of the Surviving the Teens® Suicide Prevention and Depression Awareness Program: An Impact Evaluation Utilizing a Comparison Group
Health Education & Behavior 2014, Vol. 41(6) 605–613 © 2014 Society for Public Health Education Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1090198114531774 heb.sagepub.com
Catherine M. Strunk, MSN, RN1, Keith A. King, PhD, MCHES2, Rebecca A. Vidourek, PhD, CHES2, and Michael T. Sorter, MD1
Abstract Youth suicide is a serious public health issue in the United States. It is currently the third leading cause of death for youth aged 10 to 19. School-based prevention programs may be an effective method of educating youth and enhancing their help-seeking. Most school-based suicide prevention programs have not been rigorously evaluated for their effectiveness. This evaluation employs a comparison group to measure whether program group participants differed significantly from comparison group participants on pretest–posttest measures while assessing the immediate impact of the Surviving the Teens® Suicide Prevention and Depression Awareness Program. Findings indicate several positive outcomes in program group students’ suicide and depression knowledge, attitudes, confidence, and behavioral intentions compared with the comparison group. Suicide prevention specialists and prevention planners may benefit from study findings. Keywords adolescence, injury prevention, safety, school-based mental health, social cognitive theory Youth suicide in the United States has been a serious public health issue for the past several decades (U.S. Department of Health & Human Services, 1999). It is currently the third leading cause of death for youth aged 10 to 19 years (Centers for Disease Control and Prevention [CDC], 2013a). Although the suicide rates for this age group steadily declined from 2004 to 2007, these rates have increased by nearly 16.5% (3.77-4.30 per 100,000) from 2007 to 2010 (CDC, 2013b). The largest increases were for youth aged 10 to 14. The suicide rate increased by 50% (0.86-1.29 per 100,000) for this age group from 2007 to 2010. For youths aged 15 to 19, the suicide rate increased by approximately 12.2% (6.71-7.53 per 100,000) during this same timeframe. In 2010, there were 1,926 youths aged 10 to 19 years who died from suicide. Unfortunately, for every youth suicide there are between 100 and 200 suicide attempts (American Association of Suicidology, 2008). The economic cost of suicide and suicide attempts in the United States is estimated to be $42 billion annually (American Foundation for Suicide Prevention, 2013a). Risk factors for suicide are numerous and exist on multiple levels. On a personal level, greater than 90% of suicidal adolescents have a diagnosable mental health disorder (Bridge, Goldstein, & Brent, 2006). On the family level,
adolescents experiencing abuse, dealing with the loss of a parent, and lack of family cohesion increase the risk for suicide (Hawton & James, 2005; C. A. King & Merchant, 2008; O’Donnell, Stueve, Wardlaw, & O’Donnell, 2003). In the school setting, social isolation, peer victimization, and exposure to bullying are associated with depression and suicide (Fergusson, Woodward, & Horwood, 2000; Gould, Fisher, Parides, Flory, & Shaffer, 1996; La Greca & Harrison, 2005; O’Brennan, Bradshaw, & Sawyer, 2009). Reducing risk factors is one method many programs address in the prevention of suicidal behavior among adolescents. Fortunately, students who are suicidal tend to show verbal, behavioral, and environmental warning signs (K. A. King, 2006; Rudd et al., 2006). Verbal warning signs include statements such as “I am going to kill myself,” “I want to die,” and “Everyone would be better off if I am dead” 1
Cincinnati Children’s Medical Health Center, Cincinnati, OH, USA University of Cincinnati, Cincinnati, OH, USA
2
Corresponding Author: Catherine M. Strunk, Division of Child and Adolescent Psychiatry, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, M.L. 3014, Cincinnati, OH 45229, USA. Email: [email protected]
Downloaded from heb.sagepub.com at WEST VIRGINA UNIV on May 5, 2015
606
Health Education & Behavior 41(6)
(K. A. King, 2006). Regarding behavior, warning signs include changes in school performance, changes in weight, loss of interest in once enjoyable activities, and social isolation. Environmental warning signs include a previous suicide attempt, a recent suicide attempt, or certain life stressors such as a breakup or sudden loss. Such warning signs can be recognized by other individuals; thus, it is imperative for adolescents to properly identify warning signs and seek help appropriately. Clearly, increased efforts are needed to prevent youth suicide in our nation. The Surgeon General’s Call to Action to Prevent Suicide (U.S. Department of Health & Human Services, 1999) recognizes this urgent need and offers a framework for suicide prevention that includes a number of recommendations, such as developing and implementing safe and effective school-based suicide prevention programs that “address adolescent distress, provide crisis intervention and incorporate peer support for seeking help” (U.S. Department of Health & Human Services, 1999, p. 7). This document has prompted communities across the nation to develop and implement school-based suicide prevention programs. Many of these programs are universal (Robinson et al., 2013) in nature whereby an entire population is targeted, such as youths between the ages of 12 and 18, with the overall goal of reducing risk factors or enhancing protective factors among these youths. Indicated programs, on the other hand, are designed for at-risk teens who exhibit suicide risk factors or warning signs, such as frequent suicide ideation, a previous suicide attempt, depression, or substance abuse. Unfortunately, few of these programs have been rigorously evaluated (Katz et al., 2013; Robinson et al., 2013), which makes it difficult to determine whether or not identified results are because of a program effect versus a cohort or school effect. Although many programs show a positive impact on knowledge and attitudes about depression and suicide (Miller, Eckert, & Mazza, 2009; Portzky & Van Heeringen, 2006; Robinson et al., 2013), few have shown a positive impact on help-seeking behaviors (Aseltine, James, Schilling, & Glanovsky, 2007; Ciffone, 2007; K. A. King, Strunk, & Sorter, 2011; Robinson et al., 2013). This is significant because a lack of help-seeking among youth can lead to suicide (Pagura, Fotti, Katz, & Sareen, 2009). Therefore, the purpose of this evaluation was to assess the impact on students’ help-seeking behaviors as well as the overall effectiveness of the Surviving the Teens® Suicide Prevention and Depression Awareness Program while employing a comparison group to measure whether program group participants differed significantly from comparison group participants on pretest–posttest measures.
Program Description The Surviving the Teens® Depression Awareness and Suicide Prevention Program was developed by Catherine Strunk, MSN, RN, and is offered by the Division of Psychiatry at
Cincinnati Children’s Hospital Medical Center. It is delivered in health classes in four 50-minute sessions over 4 consecutive days. The two major risk factors for suicide, depression and substance abuse (National Institute of Mental Health, 2012), are discussed in great detail throughout the program. Other mental disorders, such as bipolar disorder and schizophrenia, are also discussed. Additionally, students are taught risk factors for depression related to medical illness, family stressors, self-esteem, sexual orientation, peer/ social stressors, trauma/violence, and grief/loss and adaptive ways of coping with these stressors. Students are shown how to recognize signs of depression, suicide, and substance abuse through true stories of other teens who have dealt with these issues. Students are also taught ways to connect and better communicate with family members, anger management, and conflict resolution skills. The Surviving the Teens® program is based on the selfefficacy model of social cognitive theory (Bandura, 1998), which posits that self-efficacy beliefs are major determinants in regulating behavior and are needed to enact change. According to this model, self-efficacy beliefs can be developed in four ways, which are through mastery experiences, vicarious experiences, social persuasion, and reducing stress reactions. The Surviving the Teens® program utilizes three of these to enhance self-efficacy: vicarious experiences, social persuasion, and reducing stress reactions. Vicarious experiences are provided through social models, such as other teens who have experienced depression and successfully asked for help by taking Steps to LAST®. Social persuasion is used by the program’s educator when encouraging students to take Steps to LAST® to help oneself or to help a troubled friend when they or their friends are feeling troubled, depressed, and/or suicidal. Students are taught to manage their emotions and stress reactions through problem solving, cognitive restructuring, and use of relaxation techniques. Both sets of Steps to LAST® are behaviorally based to enhance self-efficacy. Since the Surviving the Teens® program is a 4-day program, however, students have insufficient time to develop mastery over the skills of applying Steps to LAST® in a variety of real-life situations. Nevertheless, students are provided opportunities to practice these skills through several role-play scenarios over 2 days of the program. Although the Surviving the Teens® program is universal in nature, it does target teens at-risk for suicide within the curriculum and offers tools these teens can use to help themselves in the present or in the future when dealing with depression or suicide ideation. Some school-based programs incorporate a screening tool to target teens who are at risk for suicide (Aseltine et al., 2007; Robinson et al., 2009; Waldvogel, Reuter, & Oberg, 2008). However, this approach only identifies those teens who are at current risk. Unfortunately, some teens may screen at a very low risk level at one point in time, but may quickly advance to a higher risk level at a later time (Ciffone, 2007). Therefore, the Surviving
Downloaded from heb.sagepub.com at WEST VIRGINA UNIV on May 5, 2015
607
Strunk et al. the Teens® program not only encourages teens’ seeking help for their at-risk peers but also for themselves when feeling depressed or suicidal through Steps to LAST®. These steps can be easily compared with the Heimlich maneuver since they can be used on oneself as well as someone else in crisis. These steps also employ “LAST” as an easy to remember mnemonic since it is synonymous to “survive,” which is associated with the name of the program. This mnemonic facilitates students’ remembering each step to take to help themselves or their troubled peers. For instance, Steps to LAST® to help oneself refers to (a) Let someone know what is troubling you, (b) Ask for and accept others’ support, (c) Share your feelings, and (d) Tell an adult who can help. Steps to LAST® to help a troubled teen refers to (a) Listen and look for signs of depression and/or suicide, (b) Ask specific questions about suicide, (c) Show support, and (d) Tell an adult who can help. These steps complement each other and work best when used in conjunction with one another. Students participating in the program are given cards that outline both Steps to LAST®, identify referral sources, and give the address for the program website. More details about this program and Steps to LAST® can be found on the Cincinnati Children’s website at www.cincinnatichildrens.org/surviving-teens. Some overarching goals of the program include (a) increase help-seeking behaviors among troubled youth and their peers; (b) increase family and school connectedness; (c) decrease suicidal and other risk-taking behaviors, such as illicit drug and alcohol use; and (d) improve students’ coping skills.
Method Participants Participants of this evaluation were high school health class students in Grades 9 through 12 in Greater Cincinnati area schools. Program group participants were from nine high schools who received the Surviving the Teens® Suicide Prevention and Depression Awareness Program as well as a pretest and posttest survey during their scheduled fall semester health class in 2008/2009 school year. Comparison group participants were in the same grade level in five of the same schools as program group participants, but did not receive the program until after their completing pretest and posttest surveys during their scheduled spring semester health class in 2008/2009 school year. These schools were primarily located in middle-class, suburban communities in three counties in Ohio.
Procedures Principals and health class teachers in the schools where the Surviving the Teens® was being presented were invited to participate in this impact evaluation. Participation in the program and evaluation was completely voluntary. No parents
or students refused to participate in the program and comparison group evaluations. Parents were provided an informational letter that discussed the project purpose, voluntary nature of the surveys, and potential risks and benefits. Informed consent was obtained from parents and school principals for students’ participation in this evaluation. Assent was given by the teenagers who filled out the questionnaires. Students were encouraged to answer all questions, but they were told they could skip any questions that made them feel uncomfortable in answering. Although a small percentage of students were absent for the posttest evaluation, greater than 95% of students were in each class that participated in the study. This evaluation was exempt by the institutional review board (IRB) at a Midwestern hospital. The same presenter, a mental health professional, delivered the program to participants to ensure intervention fidelity. Teachers were given written and verbal instructions by the program coordinator about administration procedures for the pretests surveys. These surveys were administered to program group participants 1 day prior to program delivery. Pretest surveys were administered to comparison group participants 4 days prior to program delivery. Posttests were administered to program group participants immediately after the program (4 days after pretest) by the program coordinator. Posttests were administered to comparison group participants by the program coordinator 4 days after the pretest and immediately before delivery of the program. All surveys were numerically coded to identify each student and school. The program coordinator reviewed the completed surveys before the end of the school day to identify any students who reported being currently suicidal. The school principal, school counselor, and parents/legal guardians were informed of those students with current suicide ideation and these students were assessed by the counselors for immediate suicide risk. If any students disclosed a clear suicide plan or expressed feeling unsafe regarding self-harm, then parents were directed to take them to a local pediatric hospital emergency room. If no suicide plan or immediate plans of self-harm were determined, then these students were referred to mental health professionals within the community. All responses were kept confidential. The program coordinator shredded and destroyed the school code list and student identifiers before transferring the surveys to the program evaluator, making all saved data anonymous.
Survey Development and Testing The survey instrument was developed based on a comprehensive review of the literature and other validated surveys developed and used by Keith King, PhD, MCHES. The following survey sections were used in this program evaluation: Section 1, Perceived Confidence in Helping a Suicidal Friend (5 items); Section 2, Perceived Importance in Knowing Suicidal Warning Signs and Steps to Take with Suicidal Friends (3 items); Section 3, Intention to Help Self or Friends
Downloaded from heb.sagepub.com at WEST VIRGINA UNIV on May 5, 2015
608
Health Education & Behavior 41(6)
if Suicidal (4 items); Section 4, Stigma Related to Suicide, Depression, and Counseling for Mental Health Issues (5 items); Section 5, Perceived Confidence in Handling and Talking about Problems (4 items); Section 6, Self-Esteem (5 items); Section 7, Frequency in Talking to Important Others about Problems (8 items); Section 8, Frequency in Ineffectively Handling Problems (3 items); Section 9, Frequency in Intending to Effectively Handle Problems (3 items); Section 10, Knowledge of Depression Risk Factors (12 items); Section 11, Knowledge of Suicide Risk Factors (11 items); Section 12, Knowledge of Suicide Warning Signs (15 items); and Section 13, Knowledge of Suicide Myths and Facts (10 items). Sections 1 to 6 requested students to rate how strongly they agreed or disagreed with each item via a 5-point Likerttype scale (1 =strongly disagree; 5 =strongly agree). An example of these items was the following: “Please check how strongly you agree or disagree with the following item: I feel confident that I can recognize a friend who is suicidal.” Sections 7 to 9 requested students to rate how frequently they engaged in each behavioral item via a 5-point scale (1 = never [0% of the time]; 2 = rarely [1% to 24% of the time]; 3 = sometimes [25% to 75% of the time]; 4 = most times [76% to 99% of the time]; 5 = always [100% of the time]). An example of these items was the following: “How often do you talk to your parent/guardians about problems you have at school?” Sections 10 to 12 requested students to check the appropriate boxes for each question. An example of these items was the following: “Check the boxes that you think increase the chances for a teen to attempt suicide: __Having a previous suicide attempt.” Section 13 requested students to check either true or false for each statement. An example of these items was the following: “Most teen suicides occur without any warning signs. __True __ False.” Face and content validity of the survey instrument were established by distributing the survey to a panel of experts for review. Suggested revisions were incorporated into the final instrument. Stability reliability of the survey was established by distributing the survey to a convenience sample of students on two separate occasions, 7 days apart. Pearson correlation coefficients were greater than .74 on all parametric subscales. Internal consistency reliability was established for parametric subscales and yielded Cronbach αs >.80.
Data Analysis Data analysis was conducted via SPSS (Statistical Package for the Social Sciences), Version 21.0. Frequency distributions, means, standard deviations, and ranges were used to describe students’ background characteristics. A series of F tests were conducted to assess potential differences in the selected dependent variables (e.g., suicide-related perceptions, helping-seeking intentions, self-esteem, frequency in communicating about problems and handling problems, and knowledge) between the program group and control group participants. More specifically, these F tests were performed
Table 1. Demographic and Background Characteristics of Respondents. Program Group Item Gender Male Female Grade 9th 10th 11th 12th Age 13 years old 14 years old 15 years old 16 years old 17 years old 18 years old Race/ethnicity American Indian African American Asian Hawaiian/Pacific Islander Hispanic/Latino White Multiracial Other
Control Group
n
%
n
%
424 542
43.9 56.1
286 280
50.5 49.5
701 233 26 14
71.9 23.9 2.7 1.5
488 58 21 2
85.6 10.2 3.7 0.4
3 368 440 137 20 4
0.3 37.9 45.3 14.1 2.1 0.4
1 192 285 78 12 1
0.2 33.7 50.1 13.7 2.1 0.2
21 40 16 4 23 822 36 5
2.2 4.1 1.7 0.4 2.4 85.0 3.7 0.5
9 24 5 0 15 474 36 4
1.6 4.2 0.9 0.0 2.6 83.6 6.3 0.7
Note. Percentages denote valid percentages; missing values excluded.
to evaluate the overall effectiveness of the Surviving the Teens® Suicide Prevention and Depression Awareness Program. Missing data were excluded from analyses. The alpha level of significant was set at .05. At baseline, analyses were conducted to identify any significant differences between the program group and comparison group. Results from these analyses revealed no significant differences between the groups based on demographic variables (sex, age, grade, family structure, grades received in past 12 months) as well as dependent variables (suicide-related perceptions, helping-seeking intentions, self-esteem, frequency in communicating about problems and handling problems, and knowledge). Therefore, the groups were deemed equivalent and no covariates were used in subsequent analyses.
Results Demographics A total of 966 students participated in the program group whereas 581 students participated in the control group. Pretest–posttest matches were obtained for students in each group. In the program group, slightly more males (56.1%) than females (49.5%) participated (Table 1). In the control
Downloaded from heb.sagepub.com at WEST VIRGINA UNIV on May 5, 2015
609
Strunk et al. Table 2. Suicide-Related Perceptions, Help-Seeking Intentions, and Self-Esteem Based on Group. Program Group Item Confidence in helping a suicidal friend Perceived importance in knowing suicidal warning signs and steps to take with suicidal friends Intention to help self or friends if suicidal Stigma related to suicide, depression, and counseling for mental health issues Confidence in handling and talking about problems Self-esteem
Control Group
Pretest, M (SD) Posttest, M (SD) Pretest, M (SD) Posttest, M (SD)
F
p
η2
18.75 (3.344) 13.29 (2.030)
21.09 (3.152) 13.63 (1.790)
19.08 (3.377) 12.83 (2.274)
19.55 (3.325) 12.61 (2.177)
124.409
