POPULATION-BASED APPROACHES TO SUICIDE PREVENTION: EMERGING ISSUES IN DESIGN OF RANDOMIZED TRIALS, HUMAN SUBJECTS PROTECTION, AND CULTURAL COMPETENCY
Chair: David Chambers
POPULATION-BASED APPROACHES TO SUICIDE PREVENTION: EMERGING ISSUES IN DESIGN OF RANDOMIZED TRIALS, HUMAN SUBJECTS PROTECTION, AND CULTURAL COMPETENCY. Peter Wyman1, David Chambers2, Gene Brody3, Jerry Reed4, 1University of Rochester, Rochester, NY United States; 2National Institute of Mental Health, Bethesda, MD United States; 3University of Georgia, Athens, GA United States; 4Suicide Prevention Action Network, Washington, DC United States
To achieve progress in reducing suicide rates, population-based prevention approaches are likely to be needed in addition to intervention approaches targeting high-risk groups. Suicide is a culminating event that arises from a variety of mental health conditions and stressful life circumstances. As a result, no single subgroup captures the majority of individuals at high risk for suicide. In addition, since death due to suicide is a low incident event, randomized trials to identify effective prevention approaches will require large samples followed over extended time-periods. Consequently, population-based prevention approaches may be both efficient and necessary to identify and implement comprehensive strategies to reduce suicide rates. An example of a population-based suicide prevention approach is 'gatekeeper' training designed to improve surveillance of individuals at high risk for suicide and to increase their access to mental health treatment.
Researchers face a number of challenges in developing effective population-based interventions for suicide prevention, as well as opportunities for innovation. In this symposium we present and discuss three such areas of challenge and opportunity. The discussant (Gene Brody) will focus on implications for creating sustainable community partnerships.
1. C Hendricks Brown will discuss new methods for designing randomized trials for suicide prevention within a general population. Four problems in designing randomized trials for preventing suicide will be described. Several recommended solutions to those problems will be presented using an example of an ongoing school-based trial involving 32 middle and high schools testing a gatekeeper-training program.
2. Peter A. Wyman will describe several of the bioethical tensions involved in conducted randomized trials of interventions for suicide prevention within a general population. An ongoing school-based trial testing gatekeeper training will be used to illustrate the bioethical dilemmas involved in such interventions and include recommendations for defining adverse events and for developing criteria for monitoring safety of human participants.
3. Sherry D. Molock will discuss challenges in developing interventions for suicide prevention in culturally diverse communities. Examples from developing interventions for suicide prevention in African American churches will be used to illustrate issues, including how to address differences in the target community's beliefs and attitudes about suicide and how to assess the validity of culture-specific program content.
NEW DESIGNS FOR RANDOMIZED TRIALS IN GATEKEEPER TRAINING IN SUICIDE PREVENTION. Peter Wyman1, Hendricks Brown2, Jing Guo2, Juan Pena1, 1University of Rochester, Rochester, NY United States; 2University of South Florida, Tampa, FL United States
In this presentation we discuss new methods for designing randomized trials for suicide prevention within a general population, using data from an ongoing randomized trial in a large school district in Georgia. There are unique problems in designing a trial for preventing suicide. First, most researchers believe there are few opportunities to use a strong statistical design with random assignment to intervention condition in community settings. Secondly, self-inflicted mortality is relatively rare, although when it does occur it is often accompanied by great suffering among families, friends, and community. The "low baserate" for suicide makes it quite challenging to design a trial with sufficient statistical power to detect impact on suicide itself. Suicidal ideation and behavior are not at all rare so impact on these outcomes is sometimes easier to examine. However, if a secondary prevention program, such as gatekeeper training, is successful, it should first be able to detect more suicidality than in community control conditions. Following this there should be more referrals to mental health professionals and as a result less completed suicides in the intervention group. Thus the third problem in designing a randomized trial for suicide prevention is evaluating not only its ability to identify suicidal youth but to follow up with appropriate referral and intervention. Finally, any secondary prevention strategy involving gatekeeper training or individual screening must mount an intensive effort to saturate the community.
In our current trial, we are testing a gatekeeper training program for all school staff using a school-based randomized wait-listed design where half of the 32 middle and high schools receive training in the first year and half in the second. The primary outcome is recent suicidal ideation or behavior as confirmed by a mental health professional after referral from the school district. We first discuss this design's solutions to the four problems listed above. We then present recommended improvements in the classic wait-listed design. These include the use of replicate samples of schools so that the training can saturate individual schools much more effectively than achievable by a standard wait-listed design.
PROTECTING HUMAN SUBJECTS IN RANDOMIZED TRIALS OF GATEKEEPER TRAINING INTERVENTIONS FOR SUICIDE PREVENTION. Peter Wyman1, Hendricks Brown2, Wendi Cross1, Karen Schmeelk-Cone1, 1University of Rochester, Rochester, NY United States; 2University of South Florida, Tampa, FL United States
There are a number of bioethical tensions inherent in conducting randomized trials of interventions designed to prevent suicide and suicidal behavior within a general population. In this presentation we discuss several challenges to conducting safe and ethical trials of `gatekeeper´ training programs, using the example of an ongoing randomized trial involving 32 middle and high schools with over 60,000 students.
One set of challenges faced by investigators and their data safety and monitoring boards (DSMBs) is in defining adverse events and in developing criteria to monitor safety of study participants. Given that a focal objective of gatekeeper training programs is enhanced detection of individuals at high risk for suicide, monitoring criteria must distinguish between evidence of improved surveillance of suicidal individuals from evidence that gatekeeper-training programs are harmful or potentially harmful to a subgroup of individuals. For example, whereas an increase in the number of suicide attempts documented by school officials may indicate iatrogenic effects of gatekeeper programs, such an increase could be evidence of improved surveillance of suicidal students who previously would have gone undetected by school officials. Distinguishing between intended and unintended effects can sharpened by establishing pre-trial levels of adverse outcomes including number of deaths due to suicide. A second tension involves balancing the objective of ensuring safety of individuals identified as suicidal within both `intervention´ and `control´ settings with the scientific objective of maintaining control sites as neutral in order to provide an accurate test of intervention impact. An additional tension stems from the fact that randomized trials of interventions targeting a general population, such as an entire school or community, must typically rely on existing monitoring and safety protocols because it is unfeasible to develop new, intensive monitoring systems for a whole population. Thus, data safety and monitoring boards must review existing monitoring and safety procedures to determine their appropriateness, but may not be able to alter such practices if they are deficient and therefore must be prepared to stop or modify an ongoing trial if necessary.
We will first discuss how we have addressed these and other ethical and safety challenges in our current trial involving 32 middle/high schools. We will describe analyses used to distinguish between expected and unexpected rates of student deaths by suicide in each intervention condition based on mortality rates during the past 15 years. We then present recommendations for protecting human subjects in future trials of gatekeeper training in schools and in other populations.
DEVELOPING CULTURAL COMPETENCY TO DESIGN & IMPLEMENT PREVENTION PROGRAMS IN CULTURALLY DIVERSE CONTEXTS. Molock Sherry1, 1George Washington University, Washington, DC United States
Prevention scientists are increasingly asked to develop and implement prevention programs in culturally diverse communities. These programs are often developed outside of the intervention context and “transplanted” into a context that may have different cultural norms, values, and priorities than the research community. This paper will address the challenge of developing and implementing culturally sensitive prevention programs by examining the following issues: 1) exploring what aspects of intervention development may be “universal” and generalizable to most communities; 2) should programs only be “need driven” from the perspective of the community; 3) acknowledging that the research community has different norms and values from the community and addressing how to reach common ground to develop and implement the intervention; 4) exploring how the role of the researcher as an “insider” vs. “outsider” to the community influences the development and implementation of interventions; 5) how does one develop culture-specific interventions that are sensitive to the needs of the community. These include the community´s beliefs and attitudes concerning the target behaviors (and the implication this has for measuring phenomena in culturally diverse communities); developing culture-specific program content and how to assess the validity of the content; enhancing skills/competencies of community members in a way that is culturally congruent; and the challenges in evaluating culturally sensitive intervention approaches.
Examples from developing interventions for suicide prevention in an ongoing program based in African American churches will be used to discuss the implications of the aforementioned issues for population based interventions. Particular attention will be paid to developing interventions that attempt to affect change at both the individual and community level and the importance of disseminating the information gleaned from the program to the community at large.
CONCURRENT 9, EPIDEMIOLOGY, Grouped papers
SPATIAL DISTRIBUTIONS OF RISK AND PROTECTIVE FACTORS IN PLANNING PREVENTION PROGRAMS, STATE PREVENTION SYSTEMS, SUBSTANCE ABUSE AND COMMUNITY LEVELS OF RISK AND PROTECTIVE FACTORS
Chair: Robert Saltz
THE RELEVANCE OF SPATIAL DISTRIBUTIONS OF RISK AND PROTECTIVE FACTORS IN PLANNING PREVENTION PROGRAMS. Sanjeev Sridharan1, 1Westat, Rockville, MD United States
In recent years, there has been an increased focus on risk and protective factors in developing State-level community monitoring system. In this paper, we discuss how a spatial analysis of risk and protective factors can help guide State-level prevention planning. Such a focus on spatial analysis is important because : (i) risk and protective factors may vary dramatically across different regions of a State and (ii) the “causal drivers” associated with risk and protective factors might vary across different regions. In the spatial analysis literature, this is referred to as spatial heterogeneity. Understanding such “causal drivers” can help design locally responsive programs. Programs designed to meet a statewide need may have little relevance to the needs of specific localities. In this paper, the utility of exploratory spatial data analysis using a study of clusters and outliers based on data for a child risk scale computed for counties in the state of Virginia. Specifically, we examine the spatial distribution of the children´s risk scale in 1995 and 2001, with a special focus on identifying significant local clusters and outliers. We chose the period between 1995 and 2001 to illustrate the importance of space-time analysis and to provide some initial insight into the effect of major policy changes on spatial distribution of risks and protective factors. Nationally, in 1997, Aid to Families with Dependent Children (AFDC) was replaced by a new federal block grant called Temporary Assistance to Needy Families (TANF). Three research questions are addressed: 1. Are risks randomly distributed across Virginia? If risks are randomly distributed, social policy focused on children, perhaps does not need to explicitly incorporate spatial information into prevention planning efforts. On the other hand, if the underlying spatial distribution of risk is not random, an argument can be made that prevention programming should explicitly incorporate spatial information and be targeted to account for the regional disparities. 2. Are there spatial clusters or “hot spots” of high risks communities? In other words, are counties that have high levels of risk surrounded by counties that also have high levels of risk? Such a focus can help in identifying counties or regions in which there might be greater need for prevention efforts. 3. Is there a relationship between spatial patterns of risks in 1995 and 2001? Given the importance of the period between these years, it would be especially useful to study the relationships between risks in those years.
PREDICTING SUBSTANCE USE USING COMMUNITY LEVELS OF RISK AND PROTECTIVE FACTORS. Michael Arthur1, M. Lee Van Horn2, J. David Hawkins1, 1University of Washington, Seattle, WA United States; 2University of South Carolina, Charleston, SC United States
Prevention scientists have articulated a model for planning community prevention services by measuring risk and protective factors in adolescent populations and prioritizing specific factors for preventive action (e.g., Arthur & Blitz, 2000; Hawkins et al., 1991; Hawkins et al., 2003). This approach is based on the hypothesis that the prevalence of adolescent problem behaviors in a community can be reduced over time by reducing elevated risks while enhancing protective factors experienced by the youths in the community. This presumes that epidemiological levels of risk and protective factors are relatively stable characteristics of communities such that assessments of the levels of risk and protection in one age cohort can be used to guide selection of prevention programs that may be delivered to subsequent cohorts. Prior studies have shown that communities vary in levels of specific risk and protective factors, and that this variation is associated with concurrent variation across communities in levels of adolescent problem behaviors (e.g., Hawkins, in press). However, it is not known whether levels of risk and protective factors in one cohort predict substance use in subsequent cohorts within the same community. The present study examined data from anonymous surveys of 8th and 10th grade students in 41 communities across 7 states, conducted in 2000 and 2002. Survey data include measures of risk and protective factors (Arthur et al., 2002; Glaser et al., in press) and lifetime and past month use of alcohol, tobacco, and marijuana. All substance use variables were dichotomized into either no use or any use. Multi-level logistic analyses were conducted regressing student substance use in 2002 on community level means for each risk and protective factor computed from the 2000 survey data, adjusted for age, sex, and ethnicity at the individual level. Analyses examined relationships between drug use among 8th grade students in 2002 and the risk and protective factors reported by 8th graders in 2000 (between cohorts), and between drug use reported by 10th grade students in 2002 and the risk and protective factors reported by 8th grade students in 2000 (within cohorts). Findings indicated that risk and protective factors measured in 2000 predicted drug use two years later among students both within and between grade cohorts. Implications for community prevention planning will be discussed.
EPIDEMIOLOGY WORKGROUPS: THE MISSING LINK IN STATE PREVENTION SYSTEMS CHANGE. Robert Orwin1, Ann Landy1, Wilbert Hardy2, Augusto Diana2, 1Westat, Rockville, MD United States; 2Center for Substance Abuse Prevention, Rockville, MD United States
The Strategic Prevention Framework (SPF) State Incentive Grant (SIG) program is newest major initiative implemented by the Center for Substance Abuse Prevention (CSAP) and may be the most significant national prevention initiative ever launched. The SPF SIG combines (1) a systems-change initiative informed by the experience of the current SIG program, (2) the maturity of contemporary prevention programming and use of evidence-based practices, and (3) state-of-the-art evaluation methods at the community, state, and national levels. SPF SIG awards have been made to 21 states. Fifteen states will serve as a comparison group. Each of the grantee and comparison state will develop and implement a State Epidemiology Workgroup (SEW) to collect, organize, analyze and interpret data on the causes and consequences of substance use. In grantee states, the SEW data will be incorporated at all stages of the implementation of the SPF. Each comparison state SEW also will be required to collect and interpret data but will not be required to use the SPF or the SEW data in planning and implementing prevention-related programs, policies, and practices. The design for evaluating program effects will provide a level of scientific rigor that has not been present in large-scale CSAP initiatives. To assess the contribution of the SEW to prevention service delivery with and without the comprehensive framework and CSAP programmatic requirements, the evaluation will compare grantee and comparison states on several dimensions, including changes in funding allocation, program selection and implementation, prevention planning activities, and evaluation activities. The authors will present the evaluation design and preliminary information about the accomplishments of grantee and comparison states.
TOWARDS COMPREHENSIVE PREVENTION ON COLLEGE CAMPUSES: REPORTS ON A SPECTRUM OF STRATEGIES
Chair: Robert Saltz
TOWARDS COMPREHENSIVE PREVENTION ON COLLEGE CAMPUSES: REPORTS ON A SPECTRUM OF STRATEGIES.Robert Saltz1, Helene White2, Robert Turrisi3, James Lange4, 1Pacific Institute for Research and Evaluation, Berkeley, CA United States; 2Rutgers, The State University of New Jersey, New Brunswick, NJ United States; 3Pennsylvania State University, University Park, PA United States; 4San Diego State University, San Diego, CA United States
While gaining attention from the public and mass media, college drinking and drug use and subsequent harm remain a serious and persistent problem for many campuses. In its call for action, the National Institute on Alcohol Abuse and Alcoholism´s Task Force on College Drinking outlined recommended a range of prevention strategies that targeted individual students (including those identified as at-risk), the student population as a whole (universal prevention), and including strategies that would affect not only the campus but the surrounding community as well.
In this symposium, we have a unique opportunity to hear reports from a set of prevention research studies that reach across the full spectrum of targets, any or all of which could be candidates for a model comprehensive prevention program. Dr. White will present on two brief interventions for student mandated for treatment because of their rule violations; Dr. Lange will discuss a strategy in which student housing is used to develop a positive group identity that de-emphasizes alcohol use; and Dr. Turissi will present results of a unique study of how a campus policy to allow alcohol sales in an entertainment venue affected (or did not) alcohol consumption among students; serving practices at the venue; and more generally, how the liberalization of alcohol sales may or may not have affected the university´s ability to “market” the venue.
Dr. Saltz will serve as discussant for this session and will highlight how disparate prevention strategies may produce synergistic effects to maximize effectiveness.
EVALUATING TWO BRIEF PERSONAL FEEDBACK INTERVENTIONS FOR MANDATED COLLEGE STUDENTS. Helene White1, Thomas Morgan1, Erich Labouvie1, Lisa Pugh1, Katarzyna Celinska1, 1Rutgers, The State University of New Jersey, New Brunswick, NJ United States
This study evaluated two brief substance use interventions for students mandated for treatment because they broke university rules regarding alcohol and drugs. Students completed a baseline assessment and were then randomly assigned to either an in-person brief motivational interview personal feedback intervention (BMI) or a written personal feedback intervention (WF). The baseline sample included 234 students (58% male) who were at low or moderate risk for substance use problems. Most students (N=222, 95%) completed a 3-month follow-up assessment. We addressed the following questions: 1) Do the interventions lead to changes in patterns of alcohol and drug use and related problems? 2) Is the WF intervention as efficacious as the BMI? 3) Can mechanisms be identified that account for the effects of the interventions? Analyses indicated that there were significant decreases in substance use and use related problems regardless of intervention condition; however, intervention condition was not a significant predictor of any use outcome. Additional analyses were conducted to examine hypothesized mechanisms (e.g., changes in perceived peer norms, readiness to change, alcohol expectancies) that might account for intervention effects. The findings have important implications for the design of effective substance use interventions for college students.
SOCIAL IDENTITY, THE SOCIAL ENVIRONMENT AND ALCOHOL USE AMONG COLLEGE STUDENTS. James Lange1, 1San Diego State University, San Diego, CA United States
Behavioral alternatives can be defined as institutionally sponsored or directed activities that (a) provide students with the opportunity to engage in alcohol free behavior (behavioral displacement) or (b) provide an environment where the risks associated with alcohol consumption are reduced (harm reduction). Alcohol-free parties, substance free housing or residential learning center (a.k.a., living-learning centers) are examples of behavioral displacement whereas designated driver or safe-ride programs would be considered examples or harm reduction alternatives. Conceptually, behavioral alternative programs can have a normative effect on the population directly participating in the activity (as well as on individuals who are not participating), which in turn may influence an individual´s perceptions of risk, attitudes and behaviors related to alcohol. Although norms are hypothesized to predict behavioral intentions and behavior (Fishbein & Ajzen, 1975), the evidence linking subjective norms to intentions is relatively weak. The results of recent studies suggest that perceived group norms may only affect individual´s behavioral intentions and actual behavior to the extent that the individual strongly identifies with a behaviorally relevant reference group (Terry & Hogg, 1996, Johnston & White, 2003). In the context of behavioral alternative programs, the use of alcohol may increase (or decrease) depending upon whether norms promote or condone drinking as well as the extent to which the individual identifies with the group. Thus, if the norm of the group is to not drink, individual highly identified with the group would be expected to drink less than individual´s who identifies less with the group. However, group identity development within the college social environment has been an understudied process.
Previous research has demonstrated lower rates of alcohol use in residential living centers and traditional dorms (Brower et al., 2003; McCabe, 2000; McCabe, 2002). For this study, we are extending this previous work by examining longitudinally, the relationship between residential living environment (residential living centers vs. traditional dormitories), social identity and the use of alcohol, tobacco and other drugs (ATOD). More specifically, we are exploring whether an individual´s strength of identification with their residential living environment mediates the relationship between residential environment and ATOD use. We expect to find that for students who live in dormitories with group norms that promote responsible drinking (or no drinking) and who strongly identify with their dorm (as a behaviorally relevant group) will report lower ATOD use than students with weaker identities.