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标题：An Outcome Evaluation of the Sources of Strength Suicide Prevention Program Delivered by Adolescent Peer Leaders in High Schools
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作者：Peter A. Wyman ; C. Hendricks Brown ; Mark LoMurray 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2010
卷号：100
期号：9
页码：1653-1661
DOI：10.2105/AJPH.2009.190025
语种：English
出版社：American Public Health Association
摘要：Objectives. We examined the effectiveness of the Sources of Strength suicide prevention program in enhancing protective factors among peer leaders trained to conduct schoolwide messaging and among the full population of high school students. Methods. Eighteen high schools—6 metropolitan and 12 rural—were randomly assigned to immediate intervention or the wait-list control. Surveys were administered at baseline and 4 months after program implementation to 453 peer leaders in all schools and to 2675 students selected as representative of the 12 rural schools. Results. Training improved the peer leaders' adaptive norms regarding suicide, their connectedness to adults, and their school engagement, with the largest gains for those entering with the least adaptive norms. Trained peer leaders in larger schools were 4 times as likely as were untrained peer leaders to refer a suicidal friend to an adult. Among students, the intervention increased perceptions of adult support for suicidal youths and the acceptability of seeking help. Perception of adult support increased most in students with a history of suicidal ideation. Conclusions. Sources of Strength is the first suicide prevention program involving peer leaders to enhance protective factors associated with reducing suicide at the school population level. Suicide accounts for more deaths among 10- to 24-year-olds in the United States than do all natural causes combined.^{1 – 3} Each year, 5% to 8% of adolescents attempt suicide, and up to one third of these attempts result in an injury requiring medical intervention.^{1 – 3} To address this public health problem, school-based suicide prevention programs have proliferated as a cost-effective and convenient way to reach adolescents; however, few have been rigorously evaluated, and only a narrow range of approaches has been used along the continuum of public health interventions.¹ Currently, school-based suicide prevention programs focus primarily on reducing individual-level risk factors by increasing identification and referral for treatment of students at high risk for suicide.⁴ The 3 major strategies involve (1) direct screening of school populations for mood, substance abuse, or suicide problems^{5 – 8}; (2) training school staff as gatekeepers to increase the identification and referral of suicidal students^{9 – 11}; and (3) hybrid programs combining educational curricula with screening to increase students' self-referral.^{12 – 14} Nearly three quarters of students referred through screening will utilize at least some treatment with intensive case management; however, minimal evaluation has been reported to determine whether referrals to usual services reduce suicide risk.¹⁵ Staff gatekeeper training increases knowledge and attitudes,^{11 , 16 – 18} but a recently completed randomized trial showed no overall increases from gatekeeper training in staff-student communication about suicide.¹¹ The Signs of Suicide program, which combined an educational curriculum with a self-screening component, decreased high school students' short-term rates of self-reported suicide attempts but did not increase use of services, suggesting that some mechanism other than treatment of mental health problems decreased suicidal behaviors.^{12 , 13} Another limitation of programs relying on referrals to address the needs of suicidal adolescents is that the programs may not suit many communities' resources. In many rural and underserved communities, where suicide rates among youths are 2 to 10 times above the national average,^{19 , 20} there is scarcity of, and low accessibility to, mental health services.²¹ Modifying socioecological factors at the population level is an alternative suicide prevention strategy that has not been systematically tested. Pertaining to the relationship systems in which adolescents interact,^{22 , 23} factors that protect high school students from suicide risk include the quality and density of relationship ties as well as the norms that are propagated within those systems.^{24 – 28} The rationale for this intervention approach comes from well-established associations between suicidal behavior and adolescents' social ties and norms. Specifically, suicidal adolescents have fewer positive connections to adults^{25 , 27} and peers^{24 , 26 , 28} and lower expectations of peer support for seeking help from adults.¹¹ Social connectedness, which encompasses social integration and support,²⁹ may reduce suicide risk through several protective mechanisms, including enhanced psychological well-being,³⁰ increased monitoring of behavior by others,²⁴ and exposure to normative social influences that encourage adaptive coping strategies.²⁹ Suicidal adolescents also have more ties to other suicidal youths, and adolescents who have a friend attempt suicide are 2 to 3 times as likely as are other adolescents to make an attempt themselves.^{24 , 31} Peer suicidal behavior may promote a perceived norm that suicide is a common-place response to distress, and adolescents are more susceptible to suicide imitation than are other age groups.³² Suicide acceptance is linked to increased suicidal behavior and planning.^{33 – 35} Sources of Strength³⁶ is built on a universal school-based suicide prevention approach designed to build socioecological protective influences across a full student population. Youth opinion leaders from diverse social cliques, including at-risk adolescents, are trained to change the norms and behaviors of their peers by conducting well-defined messaging activities with adult mentoring. The purpose is to modify the norms propagated through communication within peer groups to alter perceptions of what is typical behavior (i.e., descriptive norms) and of the social consequences for positive coping behaviors (i.e., injunctive norms).^{37 , 38} Peer leaders model and encourage friends to (1) name and engage “trusted adults” to increase youth–adult communication ties; (2) reinforce and create an expectancy that friends ask adults for help for suicidal friends, thereby reducing implicit suicide acceptability; and (3) identify and use interpersonal and formal coping resources. Changing these socioecological factors is designed to connect suicidal youths with capable adults and to reduce the likelihood that lower-risk youths will enter a trajectory that includes suicidal ideation or behavior. The use of peer leaders is well-suited to adolescence³² and is congruent with diffusion of innovations theory³⁹ and Valente's⁴⁰ social network thresholds model, which point to the importance of one's personal network in adopting new norms and behaviors. In this article, we report results from a test of the short-term impact of Sources of Strength in 18 high schools that were recruited in 2 phases from 3 states.⁴¹ The first goal of this experiment was to measure the impact of the intervention on student peer leaders. Among peer leaders, Sources of Strength was expected to increase (1) positive norms pertaining to suicide, including the acceptability of obtaining adult help for suicidal friends despite their requests for secrecy (i.e., rejecting codes of silence) and using adaptive coping strategies to manage psychological risk factors; (2) social connectedness, including increasing the number of trusted adults at school and use of formal and informal coping resources (Sources of Strength); and (3) the frequency of engaging adults to help distressed or suicidal friends. In addition, by training diverse peer leaders within each school, Sources of Strength was expected to provide well-adapted students with opportunities to influence at-risk students, thereby reducing possible iatrogenic effects that may occur by grouping at-risk adolescents.⁴² Accordingly, we also hypothesized that peer leaders who gained the most from the intervention would be those with the most maladaptive norms before training. The second goal of this experiment was to ascertain the impact of the intervention on norms about suicide and social connectedness in the full student population, including suicidal youths. After 3 months of Sources of Strength messaging, students representative of their school's population were expected to report (1) increased expectations that adults can help suicidal youths and increased acceptability of obtaining help for suicidal friends and (2) greater acceptability of help-seeking for personal distress and use of Sources of Strength resources for coping. Peer leader effects have been found to modify norms for publicly visible behaviors such as tobacco use,⁴³ but have not previously been demonstrated for norms about suicide.