Diffusion of a Peer-Led Suicide Preventive Intervention Through School-Based Student Peer and Adult Networks

Strategies and evaluation underpinning the implementation of suicide prevention training: a systematic review

BACKGROUND

Suicide prevention training programs can enhance the capacity for suicide prevention by improving the attitudes and comprehension of individuals regarding suicide and increasing their skills in supporting a suicidal person. However, little is known about how training programs are implemented and how implementation is assessed. Thus, our review aims to identify the strategies and evaluation methods underpinning the implementation of suicide prevention training programs.

METHODS

The systematic review adhered to the PRISMA guidelines and involved searches in MEDLINE, Embase, Emcare, PsycINFO, EBM Reviews, Scopus, and a forward and backward citation search following the full-text screening. Eligible studies (n = 28) reported the implementation strategy or implementation evaluation of a suicide prevention training program (PROSPERO #CRD42021288621).

RESULTS

The implementation strategies varied among three categories of training programs. Gatekeeper training predominantly utilized a train-the-trainer format and collaborations with stakeholders. Professional development training focused more on establishing supportive organizational infrastructure and extended post-training supervision. School-based curriculum training programs emphasized the distribution of educational materials and role-play activities. Surveys were the primary evaluation method, often complemented by interviews, observations, progress tracking, or focus groups. Evaluations primarily assessed acceptability, fidelity, and feasibility.

CONCLUSION

While certain training categories tend to employ specific strategies and evaluation measures more frequently than others, stakeholder collaboration, assessing content relevance, and follow-up supervision could be valuable across training programs. Tailored strategies may cater for groups with varying levels of knowledge and training in suicide prevention to enhance acceptability and feasibility. Future research should evaluate approaches that facilitate adoption and sustainability of suicide prevention training programs.

Suicide Prevention Takes a Nation: Collaborative Approaches to Universalize Suicide Prevention

Suicide is a complex public health issue impacting many children and adolescents-and their families-each year, and it requires a complex public health solution. Local, state, and national collaboratives that leverage evidence-based strategies, foster community engagement, and prioritize equity are necessary to holistically address this issue. Here, the authors discuss the necessary steps for fostering inclusive community partnerships and outline the rationale for partnering with schools, youth groups, faith organizations, parent-teacher organizations, clinical settings, and professional organizations, as well as collaborating with the juvenile justice and child welfare systems and working together to foster suicide prevention policy.

Perceptions of key stakeholders on peer led strength building program for suicide prevention among young adolescents: A qualitative study from Karnataka, India

Context

Adolescent suicides are a significant public health concern in India and understanding the intersecting perspectives becomes imperative for the prevention of various mental health concerns.

Aim

Assessing perceptions of various key stakeholders, that is, mental health experts, school and college teachers, and District Mental Health Program staff about peer-led strength building programs for suicide prevention.

Settings and Design

A cross-sectional qualitative design using two Focus Group Discussions (FGDs) with mental health experts and teachers and one FGD with DMHP staff was conducted. The sample comprised 45 participants from Bengaluru urban district.

Materials and Methods

The data were analyzed manually by the method of direct content analysis, and themes were determined using existing literature.

Results

The teachers and the DMHP highlighted the need for an intensive training program/module that is necessary to be developed in order to train the peer leaders first. The mental health experts opined that creating a network will help in easy identification of the cases and appropriate treatment could be provided without delays.

Conclusions

This study indicated that suicide is a preventable public health emergency and inaccessibility to existing as well as proper support systems was perceived as a major concern. Therefore, peer-led programs are beneficial in steering and improving help seeking behavior in suicidal adolescents.

Educational agents and institutions called into action in suicide prevention, intervention, and postvention

Introduction

Suicide is the second leading cause of death in the 15 to 29 age group worldwide, and is a severe public health problem. Adolescent and young adult individuals attend educational institutions which can play an essential role in detecting and preventing suicide. For this reason, the purpose of this research is to identify what educational institutions and agents are called into action in suicide prevention, intervention, and postvention.

Methods

The method of systematic review of the literature based on the PRISMA protocol was used. The review protocol was registered in PROSPERO (PROSPERO 2020 CRD42020189127). The systematic review yielded 66 articles published between 1990 and February 2023.

Results

The results show that a wide variety of educational stakeholders are required to intervene for suicide prevention, interventions and postvention between primary education and college. The study describes the different programs that have been provided, the countries in which they have been implemented and the agents who have been targeted. It also identifies gaps in the research on suicide in the educational field.

Discussion

Overall, educational suicide initiatives report positive effects on participants' understanding, attitudes, and beliefs regarding suicide and suicide prevention, although some studies have expressed some caution.

Exploring Naturalistic Diffusion of an Evidence-Based Mental Health Intervention across Peer Networks of Youth in Sierra Leone

BACKGROUND

Understanding the mechanisms by which evidence-based interventions (EBIs) for mental health are naturally diffused among youth in low-and middle-income countries-particularly those with histories of violence and civil unrest-can illuminate which intervention elements are most transferrable and inform scale-up decisions that support youth adjustment. This study explored the diffusion of an evidence-based mental health intervention-the Youth Readiness Intervention (YRI)-among peer networks of Sierra Leonean youth (aged 18-30) who participated in a trial of the intervention as integrated into youth entrepreneurship programs.

METHODS

Trained research assistants recruited index participants who had completed the YRI integrated within entrepreneurship training (N = 165) and control index participants (N = 165). Index participants nominated three of their closest peers. Nominated peers were recruited and enrolled in the current study (N = 289). A sub-sample of index participants and peers participated in dyadic interviews (N = 11) and focus group discussions (N = 16). Multivariate regression analysis compared YRI knowledge levels among YRI participants' peers relative to control participants' peers.

RESULTS

Qualitative findings supported the diffusion of several YRI skills and components across peer networks (i.e., progressive muscle relaxation and diaphragmatic breathing). Quantitative findings indicated that YRI knowledge was significantly higher for YRI participants' peers (β = 0.02, p < 0.00) compared to control participants' peers.

CONCLUSION

Findings suggest that diffusion of evidence-based intervention components can occur naturally among peers in post-conflict LMIC settings. Developing tools to promote the diffusion of the most transferrable EBI components across peer networks could help maximize the benefits of mental health interventions for youth adjustment and resilience in post-conflict settings.

Accounting for Context in Randomized Trials after Assignment

Many preventive trials randomize individuals to intervention condition which is then delivered in a group setting. Other trials randomize higher levels, say organizations, and then use learning collaboratives comprised of multiple organizations to support improved implementation or sustainment. Other trials randomize or expand existing social networks and use key opinion leaders to deliver interventions through these networks. We use the term contextually driven to refer generally to such trials (traditionally referred to as clustering, where groups are formed either pre-randomization or post-randomization - i.e., a cluster-randomized trial), as these groupings or networks provide fixed or time-varying contexts that matter both theoretically and practically in the delivery of interventions. While such contextually driven trials can provide efficient and effective ways to deliver and evaluate prevention programs, they all require analytical procedures that take appropriate account of non-independence, something not always appreciated. Published analyses of many prevention trials have failed to take this into account. We discuss different types of contextually driven designs and then show that even small amounts of non-independence can inflate actual Type I error rates. This inflation leads to rejecting the null hypotheses too often, and erroneously leading us to conclude that there are significant differences between interventions when they do not exist. We describe a procedure to account for non-independence in the important case of a two-arm trial that randomizes units of individuals or organizations in both arms and then provides the active treatment in one arm through groups formed after assignment. We provide sample code in multiple programming languages to guide the analyst, distinguish diverse contextually driven designs, and summarize implications for multiple audiences.

Adolescent Peers and Prevention: Network Patterns of Sexual Violence Attitudes and Bystander Actions

Peer sexual violence is a significant social problem that affects adolescents and can lead to negative mental health and developmental consequences. Peers are a significant source of influence for adolescent behavior. For example, recent studies show training teens to be bystanders can be an effective prevention strategy to reduce peer violence and harassment. Peers can also promote risky behaviors including substance use and violence. The current study examined how sexual violence-specific risk and protective attitudes (e.g., denial of peer sexual violence and positive peer prevention norms) and behaviors (alcohol use and bystander actions to prevent peer sexual violence) clustered within peer networks cross-sectionally and over time. Participants were 1,499 7th-10th graders who took surveys during an academic year and who reported having opportunity to take action as bystanders to peer sexual violence. Participants took surveys 6 months apart online in schools. Questions included nomination of best friends to capture information about peer networks. Social network analyses indicated that there was weak but significant clustering of positive prevention attitudes such as bystander denial and marginal clustering on reactive bystander behaviors to address sexual assault. For comparison, alcohol use and academic grades were analyzed and found to also cluster in networks in these data. These findings suggest that for early adolescents, peer bystander training may be influential for some key bystander attitudes and reactive sexual violence prevention behaviors as individual behaviors are not independent of those of their friends.

High-Fidelity Agent-Based Modeling to Support Prevention Decision-Making: an Open Science Approach

Preventing adverse health outcomes is complex due to the multi-level contexts and social systems in which these phenomena occur. To capture both the systemic effects, local determinants, and individual-level risks and protective factors simultaneously, the prevention field has called for adoption of system science methods in general and agent-based models (ABMs) specifically. While these models can provide unique and timely insight into the potential of prevention strategies, an ABM's ability to do so depends strongly on its accuracy in capturing the phenomenon. Furthermore, for ABMs to be useful, they need to be accepted by and available to decision-makers and other stakeholders. These two attributes of accuracy and acceptability are key components of open science. To ensure the creation of high-fidelity models and reliability in their outcomes and consequent model-based decision-making, we present a set of recommendations for adopting and using this novel method. We recommend ways to include stakeholders throughout the modeling process, as well as ways to conduct model verification, validation, and replication. Examples from HIV and overdose prevention work illustrate how these recommendations can be applied.

Risk and Protective Factors Associated with Suicidal Thoughts and Behaviors Among Maryland Middle School Students

The aim of this study was to identify independent risk and protective factors associated with self-reported suicidal thoughts and behaviors (STB) among young adolescents by examining self-report data on mental health, substance abuse, violence involvement, social and economic challenges and supports, physical health and demographics in relation to STB. Data from nearly 27,000 students who completed the 2018-19 Maryland Middle School Youth Risk Behavior Survey/Youth Tobacco Survey (YRBS/YTS) were used to identify independent risk and protective factors associated with STB among middle school students (grades 6–8; ages 11-14). Twenty-three percent of students reported lifetime suicidal ideation and nine percent reported lifetime attempt(s). Independent risk factors associated with STB include depression, substance abuse or misuse, violence involvement, bullying victimization at school or electronically, sexual activity, and sleep deprivation. Protective factors include having an adult outside of school to confide in and feeling that teachers care and provide encouragement. Interactive effects by gender and/or race/ethnicity were observed for some factors in relation to STB. These results suggest that evidence-based programs and policies at the universal and selective/indicated levels in school settings are needed and should be introduced earlier on to address the widespread prevalence of STB in young adolescents. Program planners should take into consideration social, cultural and language needs when implementing and developing intervention strategies.

A comparison of peer change agent selection methods: Evidence from a high-school based suicide preventive intervention

BACKGROUND

Peer-led interventions for adolescents are effective at accelerating behavioral change. The Sources of Strength suicide preventive program trains student peer change agents (peer leaders) in secondary schools to deliver prevention messaging and conduct activities that increase mental health coping mechanisms. The program currently has school staff select peer leaders. This study examined potential for more efficient program diffusion if peer leaders had been chosen under network-informed selection methods.

METHODS

Baseline assessments were collected from 5,746 students at 20 schools. Of these, 429 were selected by adults as peer leaders who delivered intervention content through the school year. We created theoretical alternate peer leader sets based on social network characteristics: opinion leadership, centrality metrics, and key players. Because these sets were theoretical, we examined the concordance of these sets with the actual adult-selected peer leaders sets and correlated this metric with diffusion of intervention modalities (i.e., presentation, media, communication, activity) after the first year.

RESULTS

The sets of adult-selected peer leaders were 13.3%-22.7% similar to theoretical sets chosen by other sociometric methods. The use of friendship network metrics produced peer leader sets that were more white and younger than the general student population; the Key Players method produced more representative peer leader sets. Peer opinion leaders were older and more white than the general population. Schools whose selected peer leaders had higher overlap with theoretical ones had greater diffusion of intervention media and peer communication.

CONCLUSIONS

The use of network information in school-based peer-led interventions can help create more systematized peer leader selection processes. To reach at-risk students, delivery of an indirect message, such as through a poster or video, may be required. A hybrid approach where a combination of visible, respected opinion leaders, along with strategically-placed key players within the network, may provide the greatest potential for intervention diffusion.

A Trauma- and Justice, Equity, Diversity, and Inclusion (JEDI)-Informed Approach to Suicide Prevention in School: Black Boys' Lives Matter

Black boys have been dying by suicide at an increasing rate. Although the reasons for this increase are unknown, suicide in Black boys is likely influenced by multiple, intersecting risk factors, including historical and ongoing trauma. Schools can serve as an important mechanism of support for Black boys; however, without intentional anti-racist frameworks that acknowledge how intersecting identities can exacerbate risk for suicide, schools can overlook opportunities for care and perpetuate a cycle of racism that compromises the mental health of Black youth. By recognizing their own implicit biases, modeling anti-racist practices, listening to and recognizing the strengths and diversity of Black youth, and fostering school-family-community partnerships, school psychologists can help transform the school environment to be a safe and culturally affirming place for Black youth. This paper outlines how school psychologists can apply a trauma- and Justice, Equity, Diversity, and Inclusion (JEDI)-informed approach to suicide prevention in order to more holistically support Black boys, disrupt patterns of aggressive disciplinary procedures, and improve school-based suicide prevention programs. By applying this lens across a multitiered systems of support (MTSS) framework, school psychologists can help to prevent the deaths of Black boys and begin to prioritize the lives of Black boys.

Peer network studies and interventions in adolescence

Peer influence occurs across a wide variety of behavioral domains, which is an important reason for peer-led interventions: interventions in which peers are involved in the delivery of the program. These programs are promising in combatting undesirable behaviors (e.g. risk behavior) and promoting desirable behavior (e.g. healthy lifestyle), but it was shown recently that the effectiveness of these programs is modest at best and the mechanisms underlying programs' effectiveness are poorly understood. Research is needed that promotes understanding of the relative, cumulative, and interactive impacts of different types of peer relations and unpacks the various mechanisms underlying peer selection and influence. This has the potential to yield insights that advance theory and optimize peer-led interventions.

Saving Lives: Recognizing and Intervening with Youth at Risk for Suicide

Suicide is the second leading cause of death for youth in the United States. Fortunately, substantial advances have been achieved in identifying and intervening with youth at risk. In this review, we first focus on advances in proactive suicide risk screening and psychoeducation aimed at improving the recognition of suicide risk. These strategies have the potential to improve our ability to recognize and triage youth at risk who may otherwise be missed. We then review recent research on interventions for youth at risk. We consider a broad range of psychotherapeutic interventions, including crisis interventions in emergency care settings. Though empirical support remains limited for interventions targeting suicide risk in youth, effective and promising approaches continue to be identified. We highlight evidence-based screening and intervention approaches as well as challenges in these areas and recommendations for further investigation.

Above the influence of vaping: Peer leader influence and diffusion of a network-informed preventive intervention

Using social networks to inform prevention efforts is promising but has not been applied to vaping. To address this gap, we pilot tested the peer-led Above the Influence of Vaping (ATI-V) and examined diffusion through 8th grade networks in three schools. Fifty students, nominated and trained as Peer Leaders, implemented prevention campaigns informed by communication science, including gain-loss messaging and social norming. Across schools, 86-91% of students (N = 377) completed measures (pre-post) of electronic vaping product (EVP) use and attitudes, and named close friends and adults to construct social networks. Using baseline reports, we classified students as Recent EVP Users (10%), Vulnerable Nonusers (24%), or Resolute Nonusers (66%). Peer Leaders had reach through friendship connections to students at varying risk of vaping; 12-16 weeks after Peer Leaders were trained and began implementing campaigns, 79% of Resolute Nonusers and 74% of Recent Users/Vulnerable Nonusers reported exposure to a vaping prevention message. Students with more Peer Leader friends were less likely to report recent EVP use (OR = 0.41) or intention to use an EVP (B = 0.12) on post-surveys, supporting the intervention conceptual model positing diffusion through friendship networks. Use of student-nominated peer leaders was supported by network analyses showing EVP Users integrated within the friendship network, having more high-risk friends, and fewer adult connections. This evidence is the first to show that adolescent Peer Leaders with ongoing mentoring and science-informed campaigns can potentially reduce EVP acceptability and use. Areas for refining ATI-V include increasing consistency of campaign exposure across schools.

The Influence of Organised Diffusion on Social Norms Change: Addressing Intimate Partner Violence in Nepal

Intimate partner violence (IPV) is a significant global health issue. Organised diffusion has potential to influence changes in norms that perpetuate harmful practices by spreading anti-IPV messaging throughout social networks. The Change Starts at Home intervention in Nepal leverages radio programming and community mobilisation to address the perpetration of IPV. This qualitative analysis of couple interviews at the 18-month follow-up (N = 35 individuals) seeks to evaluate how the intervention messaging diffused into the community using organised diffusion as a framework, and how this influenced any changes in norms related to the perpetration of IPV. Overall, this study provides evidence that the Change at Home Intervention effectively diffused into the community and began to promote changes around IPV norms, especially among relationships that were socially and geospatially close. This analysis demonstrates the potential for organised diffusion to facilitate social norms change around IPV.

Lived experience peer support programs for suicide prevention: a systematic scoping review

BACKGROUND

Peer-led support models have gained increasing popularity in suicide prevention. While previous reviews show positive effects of peer-led support for people with mental health problems and those bereaved by suicide, little is known about the types of lived experience peer support programs in suicide prevention and whether these are effective in improving the health and wellbeing of people at risk of suicide. The aim of this paper is to provide an overview of peer support programs that aim to reduce suicidality and are led by people with lived experience of suicide.

METHOD

We conducted a systematic scoping review, involving a search of three academic (Medline, PsycINFO, Embase) and selected grey literature databases (Google Scholar, WHO Clinical Trials Registry) for publications between 2000 and 2019. We also contacted suicide prevention experts and relevant internet sites to identify peer support programs that exist but have not been evaluated. The screening of records followed a systematic two-stage process in alignment with PRISMA guidelines.

RESULTS

We identified 8 records accounting for 7 programs focussed on peer-led support programs in suicide prevention. These programs employed a range of different designs and included a variety of settings (schools, communities, rural and online). Only 3 of the 7 programs contained data on effectiveness. With the small number of eligible programs the findings from this review are limited and must be interpreted with caution.

CONCLUSIONS

Despite the increased focus of policymakers on the importance of peer support programs in suicide prevention, our scoping review confirms an evidence gap in research knowledge regarding program design, implementation, and effectiveness. More rigour is required in reporting peer-led support initiatives to clarify the underlying definition of peer support and lived experience and to enhance our understanding of the types of current peer support programs available to those experiencing suicidality. Further, we need formal and high-quality evaluations of peer support suicide prevention programs led by people with lived experience to better understand their effectiveness on participant health across different settings and delivery modalities and to allow for comprehensive systematic reviews and meta-analysis in future.

Annual Research Review: A meta-analytic review of worldwide suicide rates in adolescents

Suicide is a leading cause of death among youth worldwide. The purpose of the current review was to examine recent cross-national trends in suicide mortality rates among 10- to 19-year-olds. This study extracted suicide mortality data from the World Health Organization's (WHO) Mortality Database for the most recent year (since 2010) from any country with available high-quality data (as defined by the WHO's guidelines). Data on access to lethal means (firearms, railways) and measures of economic quality (World Bank Income Group) and inequality (Gini coefficients) were obtained from publicly available data sources. Cross-national suicide mortality rates in youth were heterogeneous. The pooled estimate across all ages, sexes, and countries was 3.77/100,000 people. The highest suicide rates were found in Estonia, New Zealand, and Uzbekistan. Suicide rates were higher among older compared with younger adolescents and higher among males than females. The most common suicide methods were hanging/suffocation and jumping/lying in front of a moving object or jumping from a height. Firearm and railway access were related to suicide deaths by firearms and jumping/lying, respectively. Economic quality and inequality were not related to overall suicide mortality rates. However, economic inequality was correlated with a higher ratio of male:female suicides. This study provides a recent update of cross-national suicide trends in adolescents. Findings replicate prior patterns related to age, sex, geographic region, and common suicide methods. New to this review are findings relating suicide method accessibility to suicide mortality rates and the significant association between income inequality and the ratio of male:female suicide. Future research directions include expanding the worldwide coverage to more low- and middle-income countries, examining demographic groupings beyond binary sex and to race/ethnicity within countries, and clarifying factors that account for cross-national differences in suicide trends.

Social Ties Cut Both Ways: Self-Harm and Adolescent Peer Networks

Peers play an important role in adolescence, a time when self-harm arises as a major health risk, but little is known about the social networks of adolescents who cut. Peer network positions can affect mental distress related to cutting or provide direct social motivations for self-harm. This study uses PROSPER survey data from U.S. high school students (n = 11,160, 48% male, grades 11 and 12), finding that social networks predict self-cutting net of demographics and depressive symptoms. In final models, bridging peers predicts higher self-cutting, while claiming more friends predicts lower cutting for boys. The findings suggest that researchers and practitioners should consider peer networks both a beneficial resource and source of risk associated with cutting for teens and recognize the sociostructural contexts of self-harm for adolescents more broadly.