LaFramboise and Howard-Pitney2323. Allen J, Rasmus SM, Fok CCT, et al. Multi-Level Cultural Intervention for the Prevention of Suicide and Alcohol Use Risk with Alaska Native Youth: a Nonrandomized Comparison of Treatment Intensity. Prev Sci. 2018;19(2):174-85. PMID: 28786044; https://doi.org/10.1007/s11121-017-0798-9. https://doi.org/https://doi.org/10.1007/...
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Country
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United States - New Mexico |
Community
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Zuni community |
Objective
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To evaluate the effectiveness of a life-skills-focused suicide prevention program in reducing behavioral and cognitive factors identified as correlates of suicidal behavior (Zuni life skills curriculum). |
Design
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Quasi-randomized study with a control and intervention arm. Students were not randomized to each group |
Population
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Students: 128 students in the Zuni Public High School. The sample was 64% female and 36% male (83 girls, 45 boys), and ages ranged from 14 to 19 years (mean 15.9 years). Scores on the Suicide Probability Scale before intervention suggested that 81% of these students were in the moderate to severe ranges of suicide risk. 40% of students reported that a relative or friend had committed suicide. With regard to their own suicidal behavior, 18% reported having attempted suicide. Of those who had attempted, 79% had attempted two or more times, 70% had tried within six months before the intervention, 17% needed a medical visit and 22% had told no one about the attempted suicide. |
Instruments
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Suicide Probability Scale (SPS);2525. Cull JG, Gill WS. Suicide probability scale (SPS). Los Angeles: Western Psychological Services; 1989. Hopelessness Scale (HS);2626. Beck AT, Weissman A, Lester D, Trexler L. The measurement of pessimism: the hopelessness scale. J Consult Clin Psychol. 1974;42(6):861-5. PMID: 4436473; https://doi.org/10.1037/h0037562. https://doi.org/https://doi.org/10.1037/...
Indian Adolescent Health Survey (IAHS) seven-point Likert scale for self-efficacy evaluation (7PL);2727. Long KN, Long PM, Pinto S, et al. Development and validation of the Indian Adolescent Health Questionnaire. J Trop Pediatr. 2013;59(3):231-42. PMID: 23418132; https://doi.org/10.1093/tropej/fmt006. https://doi.org/https://doi.org/10.1093/...
six-point Likert scale for judgment of behavioral observation (6PL-BO); and six-point Likert scale for peer ratings (6PL-PR). |
Theoretical framework
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Bandura’s cognitive social theory using roleplay. Students were asked to enact four roleplays with a confederative client, while being videotaped. Following two warm-up roleplays, each student roleplayed two scenarios concerning adolescent suicide with the same confederative client. Both scenarios involved a situation in which suicide intervention was appropriate; however, the second roleplay presented a more serious and imminent suicide threat. Roleplays were presented in counterbalanced order, and each lasted approximately 10 min. All suicide scenarios were rated independently by two judges (American Indian), blind to group assignment, who were trained as a team for 18 hours to apply the rating criteria uniformly. Peers were asked to rate their classmates on the extent to which they were able to intervene in a suicidal situation. |
Content and delivery
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The Zuni Life Skills Curriculum consists of a program focused on life skills and cognitive and behavioral factors related to suicidal behavior. This program was structured around seven major units: building self-esteem; identification of emotions and stress; increasing communication and problem-solving skills; recognition and elimination of self-destructive behaviors; receiving suicide information; receiving suicide intervention; and setting personal and community goals. The curriculum was developed to align with Zuni values, beliefs and attitudes. This program was presented to students three times a week for 30 weeks by teachers and trained cultural resource persons. Teachers: Two non-Zuni female teachers were chosen to deliver the curriculum. They were aided by two Zuni male community members (a curriculum specialist and a mental health technician). Confederative clients: Two female university students from the Menominee and Choctaw tribes participated in the behavioral assessment of the roleplay of a person with suicidal intent. Judges: Two American Indian postgraduate students served as trained judges to evaluate the problem-solving and suicide intervention skills in a behavioral assessment using ten six-point Likert scale items ranging from 1 (strongly disagree) to 6 (strongly agree). Peer ratings: After the evaluation, a subsample of 62 students (28 male and 34 female students), evenly divided between intervention and non-intervention groups, was randomly selected from the total sample for participation in a 30-minute behavioral evaluation. Also, after the evaluation, peer ratings of classmates’ suicide intervention and problem-solving skills were obtained. In the behavioral observation, students were asked to enact four roleplays with a confederative client, while being videotaped. Following two warm-up roleplays, each student roleplayed two scenarios concerning adolescent suicide with the same confederative client. Both scenarios involved a situation in which suicide intervention was appropriate; however, the second roleplay presented a more serious and imminent suicide threat. Roleplays were presented in counterbalanced order, and each lasted approximately 10 minutes. |
Outcomes
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Psychological outcomes: hopelessness, suicide probability and depression; self-efficacy skills: suicide prevention, problem solving, active listening, anger management and stress management; behavioral observation; and peer ratings. Fidelity to the curriculum was monitored through random classroom observations by an on-site intervention coordinator, which took place on a bimonthly basis in each intervention class. |
Results
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Out of the 128 students assessed before the intervention, 98 (76%) were evaluated after the intervention. A between-groups comparison of the descriptive variables assessed before the evaluation (gender, age, grade, suicide probability, suicide attempt and other suicide history variables) was conducted. These evaluations indicated that the 30 students lost to follow-up were not significantly different from the 98 students who completed both the pre and the post-intervention evaluation. To create equivalent groups pre-intervention, the students were paired according to hopelessness and probability of suicide. Thirty-one pairs were formed and analyzed pre and post-intervention. The means and standard deviations for each post-intervention outcome were:
Hopelessness (the lower the score, the better): x̄ = 3.5, SD = 2.6 for intervention; versus x̄ = 4.6, SD = 2.9 for no intervention (P = 0.05);
Suicide probability scale (the lower the score, the better): x̄ = 54.3, SD = 11.6 for intervention; versus x̄ = 58.9, SD = 13.0 for no intervention (P = 0.07);
Depression (the lower the score, the better): x̄ = 3.3, SD = 0.9 for intervention; versus x̄ = 3.4, 1.1 for no intervention (ns);
Suicide prevention (the lower the score, the better): x̄ = 4.7, SD = 0.8 for intervention; versus x̄ = 4.7, SD = 1.2 for no intervention (ns);
Active listening (the higher the score, the better): x̄ = 4.6, SD = 0.9 for intervention; versus x̄ = 4.5, SD = 1.0 for no intervention (ns);
Anger management (the lower the score, the better): x̄ = 5.1, SD = 1.1 for intervention; versus x̄ = 4.5, SD = 1.5 for no intervention (P = 0.03);
Stress management (the lower the score, the better): x̄ = 4.5, SD = 0.9 for intervention; versus x̄ = 4.5, SD = 1.6 for no intervention (ns).
Roleplays by 28 of the 62 paired students (14 in the intervention group and 14 in the non-intervention group) were evaluated by the judges. Significant improvements in suicide intervention and problem-solving were reported for the intervention group. In the peer evaluation, there were no perceived significant differences for these skills. |
Main findings
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This study found that merging a socially cognitive life-skills approach with peer support was effective for reducing some of the risk factors and increasing some of the protective factors associated with suicide. |
RE-AIM framework
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Reach: 128 students measured pre-intervention and 98 measured post-intervention, after eight months of intervention. The sample was 64% female and 36% male (83 girls and 45 boys), and ages ranged from 14 to 19 years, with a mean age of 15.9 years. Effectiveness: Theory-based intervention improved suicide intervention and problem-solving skills. Adoption: Extensive community input during the development of the curriculum. Trained Zuni members helped to deliver program. Implementation: Fidelity to the curriculum was observed bi-monthly by on-site intervention coordinator. Costs of the intervention were not reported. Maintenance: Intervention was maintained over 30 weeks of the school year. No evaluation post-project was reported. |
Allen et al.2222. Schünemann H, Brożek J, Guyatt G, Oxman A. GRADE handbook for grading quality of evidence and strength of recommendations. Updated October 2013. The GRADE Working Group; 2013. Available from https://gdt.gradepro.org/app/handbook/handbook.html. Accessed in 2021 (Oct 25). https://gdt.gradepro.org/app/handbook/ha...
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Country
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United States - Alaska |
Community
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Yup’ik community |
Objective
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To compare the effectiveness of high-intensity Qungasvik intervention in one community (treatment), with a lower-intensity intervention in a second community (comparison) that implemented fewer modules of the same intervention. |
Design
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Dynamic wait-list design |
Population
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Community 1: fifty-four Yup’ik youths (23 males and 31 females) aged 12-17 years (mean 14.24 years; SD = 1.72) who were community residents. Community 2: seventy-four Yup’ik youths (54 males and 20 females) aged 12-17 years (mean 14.62; SD = 1.82) who were community residents. |
Instruments
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Multi-level theory-of-change measurement model (MTCM), based on the assumption that change in intermediate variables at the community, family, peer and individual levels leads to change in two ultimate outcome variables measuring protection from suicide and alcohol-use disorder risk. |
Theoretical framework
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Using a community-based participatory framework, Yup’ik communities over the past 25 years have guided a melding of these two worlds, by generating the Qungasvik “toolbox”, a cultural intervention based on a local indigenous theory of personal and community change, and then collaborating with university researchers to describe it using the methods of western science. In contrast to most American Indian and Alaskan Native preventive interventions that are problem-focused and individual-level, this intervention is strengths-based and multi-level. |
Content and delivery
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‘Qungasvik’, a Yup’ik word for toolbox, is a strengths-based, multi-level, community/cultural intervention for rural Yup’ik youths. The intervention is grounded in local practices that are distinctive to rural Yup’ik communities, in order to promote modules on reasons for life and sobriety. The modules focused on issues relating to the individual, family or community level, and were delivered in one or more one to three-hour sessions. Each module promoted two to four out of 13 protective factors that had been identified in a culture-specific model of protection: individual characteristics (mastery-friends and mastery-family); family characteristics (cohesion, expressiveness and conflict subscales); community characteristics (support and opportunities, as two protective community subscales); peer influences (two scales from the American Drug and Alcohol Survey); reflective processes; and reasons for life. The same program was delivered in two Yup’ik communities. The Qungasvik intervention manual is not prescriptive. It outlines 26 modules, along with a process for community adaptation to local customs and circumstances, taking into account the current season and advice from community members. The co-researchers observed that the adaptive process resulted in greater community ownership and intervention that was more ecologically valid for the distinctive characteristics of each remote community in the region. |
Outcomes
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Intermediate outcomes: individual characteristics (mastery-friends and mastery-family); family characteristics (cohesion, expressiveness and conflict subscales); community characteristics (support and opportunities, as two protective community subscales); and peer influences (two scales from the American Drug and Alcohol Survey). Ultimate outcomes: Reflective Process (RP), consisting of the youths’ reflections on the potentially negative consequences from drinking alcohol that have elements of culture-specific meaning; and Reasons for Life (RL), which is a cultural adaptation and strengths-based extension of the Brief Reasons for Living Inventory for Adolescents. |
Results
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In community one, the youths attended a mean of 6.78 modules (SD 6.76), while in community two, the youths attended a mean of 2.31 modules (SD 3.24). Mixed-effects regression models contrasted the treatment and comparison arms, and identified that the treatment had a significant effect on Reasons for Life (d = 0.27; P < 0.05) but not on Reflective Processes, thus favoring the greater intervention that was delivered in community one. Qungasvik aimed to promote protection from co-occurring suicide and alcohol risk, but no significant findings were observed regarding alcohol protection, and there were no differences in intermediate outcomes between the communities. The more intensive intervention (compared with the less intensive intervention) resulted in a positive impact on RL (d = 0.28; P < 0.05), but not on RP or intermediate variables. This was interpreted as a finding that the intensive intervention produced significantly greater growth in protection from suicide, but not for alcohol risk. The analyses found that there was significant growth over time within the intensive group, but not in the less intensive intervention group, regarding RL (d = 0.43; P < 0.05) but not in relation to RP. There was also significant growth within the intensive group regarding individual characteristics (d = 0.34; P < 0.05), but not in relation to family or community characteristics. Peer effects grew in the less intensive group, but not in the intensive intervention group (d = 0.50; P < 0.01). |
Main findings
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The Qungasvik intervention had a protective effect on suicide risk among rural Yup’ik Alaskan Native youths. A high-intensity version of the Qungasvik intervention produced significantly greater intervention impact than did the low-intensity intervention. A protective effect was found against the risk of suicide among rural young native Yup’ik with improved mean scores for individual characteristics, family characteristics, community characteristics, reasons for life and reflective process. |
RE-AIM framework
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Reach: 54 participants (23 males and 31 females) in community 1; and 74 participants (54 males and 20 females) in community 2. Twelve percent of the target population was lost to follow-up. The mean age and SD in community 1 were 14.24 (1.72); the mean age and SD in community 2 were 14.62 (1.82). Effectiveness: The theory-based Qungasvik intervention had a protective effect against suicide risk among rural Yup’ik Alaskan Native youths. Adoption: Community adaptation to local customs and environment, with advice from people with cultural knowledge and leadership (e.g. community elders). Implementation: Systematic process for ensuring adherence to protocols, including planning of activities as a group, identifying people with expertise to carry out the activity and debriefing on where the activity succeeded in its goals and what has been learned. Maintenance: Modules focused on individual, family, and community level factors and were delivered over a one-year period. No evaluation post-project was done. |