Achieving Success

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Achieving Success

• David Litts, OD, FAAO
• Ramya Sundararaman, MD, MPH
• April 2006

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The work of suicide prevention must occur at the
community level, where human relationships
breathe life into public policy. David
Satcher, MD, PhD Sixteenth Surgeon General
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Prevention goes beyond changing individuals--it
changes cultural norms --Murray Levine
(1998)The National Strategy for Suicide
Prevention is designed to be a catalyst for
social change with the power to transform
attitudes, policies and services. -- The
National Strategy (2001)
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Community

• ...not just the sum of its citizens, but rather
  the web of relationships between people and
  institutions that hold communities together.

Wallack L and Dorfman L Media advocacy a
strategy for advancing policy and promoting
health. Health Education Quarterly 1996,
23293-317.
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Community CapacitySocial Capital

• Extent to which community members
• Demonstrate a sense of shared responsibility for
  the general welfare of the community and its
  members, and
• Evidence collective competence in confronting
  situations that threaten the integrity of the
  community and the safety and well-being of its
  members.

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Community Types
Collective Competence
Low
High
Anomic Communities LL
Detached Communities LH
Low
Shared Responsibility
Intentional Communities HL
Empowered Communities HH
High
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Norms of Communities Empowered for Suicide
Prevention

• Interdependence -- interconnectedness
• My brothers keeper -- shared responsibility
• Knowledge and skills
• Positive attitudes toward help-seeking
• Accurate understanding of mental health and
  mental illness

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Necessary Conditions

• Prevention
• Knowledge base
• Political will
• Social strategy

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Political Will Social Strategy

• Leadership ?
• Coalition ?
• Organization ?
• Resources ?
• Planning ?
• A Plan ?
• Implementation ?
• Evaluation ?

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Course Outline

• Key Terms
• Data-Driven Prevention Planning Model
• Framework for PreventionPublic Health
  Interventions
• Coalitions
• Understanding Data
• Selecting Priority Populations
• Selecting Interventions
• Logic Models and Evaluation
• Making It Work

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Suicidal Mind

• Psych-ache -- Do not necessarily want to die,
  but want to end the psychological pain.
• Constrained thinking cannot find constructive
  alternatives to suicide

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Ecological Model
Community
Individual
Peer/Family
Society
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Suicide and Mental Illness

• 90 have diagnosable mental or substance abuse
  disorders or both
• 60 have unipolar depression
• Aggressiveness, anxiety, agitation
• Other associated mental health problems
• Schizophrenia
• Bipolar disorder
• Personality disorders, e.g., borderline
• Anxiety disorders

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• Exercise Justina
• Individual
• Family/Peer
• Community
• Society

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Academic problems Mental health disorder Bullying
victim Recent significant loss Parental
Psychopathology
Family cohesion Resiliency Self esteem Problem
solving skills Social support
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What causes suicide?Over 90 of people who die
by suicide have a diagnosable mental health
disorder, substance abuse disorder, or both.
Would it be accurate to say, mental illnesses
cause suicide? Why or why not?
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Intervention Strategies

• 1. High Risk
• 2. Population-Based

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Intervention Strategies

• High Risk - More than average risk factors, less
  than average protective factors, or both
• Selectivetargets sub-populations at heightened
  risk
• Ex skill building courses for juvenile
  offenders
• Indicatedtargets individuals high risk or with
  signs or symptoms
• Ex. Mental health treatment for major depressive
  disorder

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High-risk Approach(Selective or Indicated)
Mortality threshold
Identify individuals or groupsat heightened risk
Population
Low High Suicide risk
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High-risk Approach(Selective or Indicated)
Mortality threshold
Intervene/treat
Population
Low High Suicide risk
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Roses Theorem

• A large number of people at small risk may give
  rise to more cases of a disease than a small
  number who are at high risk.
• Rose, G. The Strategy of Preventive Medicine.
  Oxford University Press, 1991.

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We are on a treadmill to nowhere if all our
efforts are directed at helping individual
victims..It is well-known public health doctrine
that no mass disorder afflicting humankind has
ever been eliminated or brought under control by
treatment of affected individuals. Only
successful efforts at primary prevention reduce
the rate of distress in the future. --
George Albee

• Albee, G. (1996). Editorial Primary Prevention
  Means a Change in Business as Usual.
• J Nerv Ment Dis, 184(2).

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Population-Based Approach(Universal)
Mortality threshold
Move population risk
Population
Low High Suicide risk
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USAF Community Prevention Partners

• Family Advocacy
• Child Youth
• Chaplains
• Criminal Investigative Svc.
• CDC
• Walter-Reed Army Inst. Of Research

• Medics-Mental Health
• Public Health
• Personnel
• Command
• Law Enforcement
• Legal

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Intervention
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Addressing risk factors across the various
levels of the ecological model may contribute to
decreases in more than one type of violence.
Violence A global public health problem, World
Health Organization, 2002, p. 15.
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Results
Knox, K, et al., Risk of Suicide and related
adverse outcomes after exposure to a suicide
programme in the US Air Forcecohort study.
British Medical Journal, December 13, 2003.
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Exercise Resource Sheet 2a

• Classify interventions on worksheet
• UniversalTarget entire population regardless of
  risk
• SelectiveTarget subgroups at heightened risk
• IndicatedTarget individuals with signs and
  symptoms

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Problems are complex and go beyond the capacity,
resources, or jurisdiction for any single person,
program, organization, or sector to change or
control.
Lasker R., Weiss E., Broadening Participation in
Community Problem Solving A Muiltidisciplinary
Model to SupportCollaborative Practice and
Research. Journal of Urban Health Bulletin of
the New York Academy of Medicine. Vol 80,No 1.
March 2003. p.5.
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Coalition

• Benefits
• Sustainability
• Varied perspectives
• Shared responsibility
• Efficient use of resources
• Challenges
• Under-representation of minorities
• Competing stakeholders (e.g., healthcare
  organizations.)
• Competing causes
• Personalities Process Vs Action

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Successful Coalitions

• Leadership
• Membership
• Process
• Sustainability

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Coalition LeadershipA Different Kind

• May be shared among several people
• Value diversity of perspective
• Able to bridge diverse cultures
• Comfortable sharing
• Ideas
• Resources
• Power

Lasker R., Weiss E., Broadening Participation in
Community Problem Solving A Muiltidisciplinary
Model to SupportCollaborative Practice and
Research. Journal of Urban Health Bulletin of
the New York Academy of Medicine. Vol 80,No 1.
March 2003.
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Coalition Not Just Good Hearted People

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Exercise

• Choose an at-risk population in your community
  for whom you would like to reduce suicide risk.
  Propose the ideal coalition for the work.

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Injury Deaths Worldwide2000
In Thousands
World Health OrganizationMay 2003
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12
39
21
11.7
28
7.5
15
29
30
17.5
10.7
7
8
3.5
22
3.1
11
19
2
5
4.1
6.4
Source World Health Organization
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Suicide Among Leading Causes of Deaths United
States - 2002
Age Groups
5 - 14
15-24
25-34
45-64
35-44
Source National Center for Health Statistics
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Suicide Eleventh Leading Cause of Death for All
Ages
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Years of Potential Life Lost Before Age 65 Years
by Cause of DeathUnited States -- 2002
Unintentional injury adverse effects
Malignant neoplasm
Heart disease
Perinatal
Suicide
Homicide
Congenital anomalies
HIV
Cerebrovascular disease
Liver disease
Source National Center for Health Statistics
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Numbers and Rates

• Suicide Number of SuicidesRate Total
  Population
• Consider
• Sample size
• Time frame

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U.S. Suicides by Age Rates Numbers, 2002
Source National Center for Health Statistics,
2002
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Suicide Rates by Age, Race, and Gender United
States -- 2002
Source National Center for Health Statistics
Note non-Hispanic ethnicity
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Suicide Rates by Age, Race, and Gender United
States - 1999-2002
Source National Center for Health
Statistics Note non-Hispanic ethnicity
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Suicide Rates United States, 1933-2002
Source Natl. Center for Health Statistics Rates
prior to 1999 Age-adjusted to 1940 U.S.
population1999 and after adjusted to 2000.
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Age-adjusted suicide rates among all persons by
state -- United States, 1999-2002
12
12
19
6.3
6.2
6.6
10.2
20
11
12
13
19
16
11
19
Rates per 100,000 population 0.0 to 9.1 9.2 to
11 11.1 to 13.4 13.5 to 21.1
Source CDC vital statistics
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The Iceberg
1900 ED Visits/Day for Self-Inflicted Injuries
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Suicidal Behaviors Among High School Students
U.S. 2003
Source CDC Youth Risk Behavior Survey During
the 12 months preceding the surveyOne or more
times So sad or hopeless almost every day for at
least 2 weeks that stopped doing usual activities
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Exercise 4

• A county with 20,000 high school students
  experienced four or more suicides annually, three
  years running among youth aged 14-18. In the
  year after conducting assemblies in every high
  school to raise awareness of suicide and suicide
  prevention, the county experienced only one
  suicide in this age group.

Assemblies
Discuss the difficulties associated with
interpreting these data.
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Finishing the Assessment

• Selecting priority populations, risk and
  protective factors
• Assessing community readiness (political will)
• Assessing community resources (assets)

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Criteria to Consider

• Impact How many people are affected? What is
  the economic impact (lost productivity, treatment
  and rehabilitation costs)? What is the impact on
  families and the community?
• Importance How important is this problem
  compared with other pressing community problems?
  What is the associated attributable risk or
  protection?
• Known intervention Is this problem amenable to
  prevention? To treatment? Is there a known
  solution?
• Neglected need Is this problem being addressed
  by other local, State, or Federal agencies or is
  this problem being neglected?
• Sound data Are the data used to identify the
  problem relevant and accurate?

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Stages of Community Readiness

• Tolerance/no knowledge
• Denial
• Vague awareness
• Preplanning
• Preparation
• Initiation
• Institutionalization/stabilization
• Confirmation/expansion
• Professionalization

(Excerpt from Community Readiness for Drug Abuse
Prevention Issues, Tips and Tools, 1997,
National Institute of Drug Abuse, p. 13-15)
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ResourcesBe Creative

• New Line Item
• Realigning existing resources
• In kind
• Networking
• Grants/fundraising
• Human resources
• Volunteers
• Paid staff
• Idea people
• Action people
• Technical assistance/prevention support

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Resources
The best and most effective prevention programs
are ones that are directed toward using resources
which are indigenous to a particular
communityexternal programs generally dont work
as well, as they dont recognize the values of
the culture. --Sherry Davis Molock, M.Div.,
Ph.D.
Preventing Suicide The National Journal, Vol. 2,
No. 3, p. 9, July 2003.
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Criteria to Consider

• Evidence-Base (Effectiveness)
• Shown to achieve desired outcome
• Reduce risk
• Increase protection
• Reduce prevalence/incidence of suicidal behaviors

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Criteria to Consider

• Evidence-Base (effectiveness)
• Achieves desired outcome
• Multi-layered

Programs that address risk and protective
factors at multiple levels are likely to be most
effective. Research suggests that coping skills
can be taught.
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Criteria to Consider

• Evidence-Base (effectiveness)
• Achieves desired outcome
• Multi-layered
• Addresses risk and protective factors

focusing on protective factors such as
emotional well-being and connectedness with
family and friends was as effective or more
effective than trying to reduce risk factors in
the prevention of suicide.
Borowsky IW, et al. Suicide attempts among
American Indian and Alaska Native youth risk and
protective factors.Archives of Pediatrics and
Adolescent Medicine, 1999, 153 543-547.
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Criteria for Selecting an Intervention

• Evidence-Base (effectiveness)
• Achieves desired outcomes
• Multi-layered
• Address Risk and protective factors
• Cost Feasibility
• Sustainability
• Political acceptability
• Social will
• Possible unintended consequences

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Interventions to Consider

• Increasing awareness and political will/
• Changing cultural normssocial marketing
• Interventions
• Developing community capacity for suicide
  prevention
• Gatekeeper training
• Coalition building
• Clinical and social services
• Education, training, linkages between social
  services and health care
• Crisis lines
• Access to effective treatments
• Strength-based approaches mentoring, coping
  skills, connectedness
• Survivor support
• Means restriction
• Firearms, pharmaceuticals/drugs, incarcerated
  populations
• Media practices
• Surveillance and research

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Were do you go for information?

• 1. SPRC Evidence-Based Practices Registry
• 2. National Registry of Effective Programs and
  Practices
• 3. Your Prevention Support Specialist at SPRC
  Patrice Melvin, pmelvin_at_edc.org, 617-618-2424

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The impulse to invest only in proven approaches
should not be an obstacle to supporting promising
ones. Promising approaches are those that have
been evaluated but require more testing in a
range of settings and with different
populations.Violence is far too pressing a
problem to delay public health action while
waiting to gain perfect knowledge.
Violence A global public health problem, World
Health Organization, 2002, p. 16.
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Exercise

• Considering the risk/protective factor resource
  sheet, and criteria for selection, small teams
  will design multi-layered interventions for these
  settings
• school
• workplace
• juvenile justice
• tribal community
• aging population

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• Situation
• Crisis center operators are unaware of newly
  expanded and available mental health services.
• Inputs
• Obtain county educational grant for
  community-based organizations.
• Identify expert in local mental health services
  to speak to hotline operators.
• Activities
• Implement new hotline training program
• Outputs
• Individuals Completed Training
• Outcomes
• Increased knowledge among hot line operators
• Increased effectiveness with callers
• Increased support perceived by callers
• Decreased suicidal feelings and thoughts
• Decreased suicide attempts

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What is a Logic Model?
If you accomplish your planned activities,
then you will hopefully deliver the amount
of product and/or service that you intended
If these benefits to participants are achieved,
then certain changes in organizations, communities
, or systems might be expected to occur
Situation/Circumstance
If you accomplish your planned activities to
the extent you intended, then your
participants will benefit in certain ways
If you have access to them, then you can use
them to accomplish your planned activities
Certain resources are needed to operate
your program
Resources/ Inputs
Activities
Outputs
Outcomes
Impact
Your Planned Work Your Intended Results
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Why develop logic models?

• Summarize the key elements of your program
• Explain the rationale behind program activities
• Clarify the differences between the activities
  and the intended outcomes of the program
• Show the cause-and-effect relationships between
  the activities and the outcomes
• Help you identify the critical questions for your
  evaluation
• Communication with policy makers, funders

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Basic Logic Model Development Template
Situation/Influencing Factor The condition that
brings about the need foran intervention
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Key Concepts

• There is no perfect logic model for any
  programwhat is important is that your logic
  model is
• complete
• consistent
• reasoned
• agreed to by the key stakeholders

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Resource Sheet 7-2Logic Model Template

• Create a Logic Model of one of the following
  conditions/interventions
• Access to firearms in home contribute to suicide
  toll Counseling by primary care providers on
  safe storage/access to firearms
• No place for people in crisis to turn establish
  a suicide prevention and crisis hotline
• Suicidal students not identified train school
  personnel to be gatekeepers
• Students in crisis speak to peers first create a
  peer counseling program in the school
• Depression undetected and under-treated educate
  physicians about the most effective approaches to
  detect and treat depression
• Juvenile justice clients have high rates of
  suicidal behavior implement a suicide risk
  screening program.

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Basic Logic Model Development Template
Situation/Influencing Factor
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Evaluation
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Reasons for Evaluating

• Prove (Outcome Evaluation)
• Whether an intervention worked (Outcomes)
• That the intervention translated to the community
  (Impact)
• Improve (Process Evaluation)
• Ensure completion of planned activities (Outputs)
• Strengthen project
• Build capacity
• Create a participatory process

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Steps in Evaluation

• Determine focus areas
• List major questions in each focus area
• Specify indicators that would answer the
  questions
• Determine kinds of data you will need
• Design methods to gather the data
• Determine a target as an agreed upon measure of
  success
• Consider necessary technical assistance
  evaluation and data management expertise

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Selecting Indicators for Evaluation
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Resource Sheet 8Developing an Evaluation

• Choose one focus area on your logic model and
  develop an evaluation component for that area.
• Classify the evaluation as Process or Outcome.

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Taking Action
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Community Types
Collective Competence
Low
High
Anomic Communities LL
Detached Communities LH
Low
Shared Responsibility
Intentional Communities HL
Empowered Communities HH
High
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Norms of Communities Empowered for Suicide
Prevention

• Interdependence -- interconnectedness
• My brothers keeper -- shared responsibility
• Knowledge and skills
• Positive attitudes toward help-seeking
• Accurate understanding of mental health and
  mental illness

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(No Transcript)
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Interventions to Consider

• Increasing awareness and political will
• Changing cultural normssocial marketing
• Interventions
• Developing community capacity for suicide
  prevention
• Gatekeeper training
• Coalition building
• Clinical and social services
• Education, training, linkages between social
  services and health care, e.g, crisis centers
• Access to effective treatments
• Strength-based approaches mentoring, coping
  skills, connectedness
• Survivor support
• Means restriction
• Firearms, pharmaceuticals/drugs, incarcerated
  populations
• Media practices
• Surveillance and research

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Suicide Prevention Is My BusinessResource Sheet
9Discussionwww.sprc.orginfo_at_sprc.org1-877-G
ET SPRC
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Public Health Model