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Peer-support suicide prevention in a non-metropolitan U.S. community.

Suicide is the third leading cause of death for 15- 19-year-olds and exceeds all natural causes of death for youth in this age group (National Center for Health Statistics, 2007). Each year, countless adolescents require medical attention for self-inflicted injuries (CDC, 2006). The impact of these deaths and potential years of life lost led to the Garrett Lee Smith Memorial Act to develop, implement, and evaluate prevention programs for youth (Youth Suicide Early Intervention and Prevention Act of 2004). Given added resources, suicide prevention has become an important focus for children, adolescents, and college students. Nevertheless, suicide risk assessment is a daunting task that is sometimes considered to be unachievable (Hallfors et al., 2006).

In prevention studies, measurement of suicidal behaviors can be challenging due to low base rates for suicide deaths. Rodgers, Sudak, Silverman, and Litts (2007) characterized the conflicting need for outcomes studies as a "measurement conundrum" in which programming effectiveness should be determined by decrease in deaths, but unattainable in the absence of vast sample sizes. As a result, intermediate factors in prevention such as increased knowledge and perceived efficacy are potential mediating factors in primary prevention and important constructs for measurement in prevention studies.

Mental health problems that are detected later in life often begin in youth (age 12-24 years) (Patel, Flisher, Hetrick, & McGorry, 2007). Thus, primary prevention efforts that minimize the burden of depression, anxiety, and other possible precipitates (e.g., poor impulse control, maladaptive problem-solving) to self-harm behavior are critical. Here, we briefly outline the status of youth suicide risk and prevention and the necessity for non-metropolitan and rural efforts. Finally, we provide evaluative data for the LifeSavers' peer support, suicide, and crisis prevention program.

Though the path to a suicide attempt varies, studies have suggested that low self-esteem and hopelessness are key factors in youth suicide risk (Overholser, Adams, Lehnert, & Brinkman, 1995; Roberts, Roberts, & Chen, 1998). Other factors include negative life events (Rudd, Joiner, Jobes, & King, 1999; Shaffer et al., 2001), psychopathology (Apter et al., 1998), and impulsivity (Apter et al., 1995) in addition to disrupted familial environment, low economic status, sense of isolation, presence of mood disorder, interpersonal conflict, and availability of drugs/alcohol and lethal means (Maris, Berman, & Silverman, 2000). These are all important targets for prevention efforts. Untreated problems may escalate in college settings where suicide has been identified as the second leading cause of death (CDC, 1997). One objective outlined in the National Strategy for Suicide Prevention was to "increase the proportion of school districts and private school associations with evidence-based programs ... designed to prevent suicide" (U.S. Department of Health and Human Services, 2001, p. 64). Unfortunately, investigations of youth suicide prevention programs are either nonexistent or are plagued by methodological problems (see Lewis & Lewis, 1996) yielding very few evidence-based programs for any age group (see Rodgers, Sudak, Silverman, & Litts, 2007 for review).

Though available studies typically omit theoretical mechanisms for youth suicide prevention programs, peer gatekeeper programs are said to be successful because peers are more "in touch" (Konet, 1990; Lewis & Lewis, 1996). Social ties, interdependence, and trust occur more readily among similar, in-group others and foster an environment that is more prepared to intervene in the event of emerging crisis. According to youth who participated in the Signs of Suicide (SOS) training, participants' fear of reporting concerns to adults was a primary complaint of the program (Aseltine & DeMartino, 2004). Gould (2003) posited that teens are simply more likely to discuss problems with other teens. In sum, peer helper programs, whereby trained teens help others who are troubled by difficulties (e.g., parent conflict, isolation) that could lead to a suicide attempt if unaddressed, may be beneficial.

Naturally, prevention efforts should be implemented in those settings for which the need is greatest. It is notable that suicide deaths occur more frequently in non-metropolitan, rural, less densely populated areas (cf.Goldsmith, Pellmar, Kleinman, & Bunney, 2002). Still, relatively few studies have explored prevention efforts in rural, non-metropolitan U.S. subgroups including youth in rural communities. In a study of rural high school students, suicide risk was associated with parental physical abuse, parent-related stressors, poor adult support outside the home, running away from home, pressure to have sex, separation from parents, and acquaintance with a suicide death victim (Wagner, Cole, & Schwartzman, 1995). Unfortunately, residents of rural America experience limited access to mental health care and insurmountable mental health-related stigma ("Lost in Rural America," 2000). Adcock, Nagy, and Simpson (1991) observed that, nationally, rural high school students are less informed on common signs of suicide than students in urban areas. Mann et al. (2005) identified physical education, means restriction, and gatekeeper education as the most promising interventions. However, some attention to the limited resources in rural communities in particular warrants some effort to take advantage of community (including peer) resources.

Note also that while suicide prevention activities often occur in school settings, less than 1% of suicide deaths occur in schools (DeVoe et al., 2005). Thus, the need to promote peer support in and outside school settings is both logical and practical. The current study explores youth peer support via the LifeSavers program in a non-metropolitan, rural setting to contribute to the scientific evidence of suicide prevention. We hypothesized that youth who participated in the LifeSavers Training program would increase in (1) knowledge and positive attitudes, (2) self-esteem, and (3) self-acceptance.


Intervention Training

The LifeSavers training program was implemented by LifeSavers Training Corporation, a not-for-profit corporation and registered charitable organization. Training "retreats," which began in 1987, have been conducted for youth at a retreat camp site in rural Illinois. The three-day manualized, weekend retreats consist of small and large group activities organized to train high school students how to (1) work together as a team, (2) listen without judgment to others' concerns, (3) recognize the signs of a peer who may be depressed and suicidal, and (4) enlist the aid of a professional counseling resource or other adult as needed. In the course of the retreat, youth participate in "listening circles" in which trainees learn to express thoughts and feelings, maintain confidentiality, and demonstrate sensitivity to others. The "listening circles" are led by past LifeSavers' trainees who have volunteered as such in their respective schools and have undergone advanced training to become group leaders.

Potential trainees are identified via current school LifeSavers, teachers, school counselors, school coaches, and other adult LifeSavers' advisors. The process of selection is semi-random in that any student who is perceived to demonstrate or have the capacity for good listening skills and empathy toward others is recruited to participate in LifeSavers training. At present, there are no exclusion criteria for students who are interested in the LifeSavers' training program.


Participants for the current study were 63 high school students who attended the LifeSavers training program in the rural southern Illinois region. The students were enrolled in 10 schools in non-metropolitan communities. In this sample, eight of the ten counties in which participants were enrolled were designated non-metropolitan. The two schools that were located in countries labeled "metropolitan" were located near metropolitan areas, but reported populations of less than 10,000. Appropriate parental consent and youth assent were obtained before students voluntarily participated in the study. They were told the study would assist in the development of the training program.


LifeSavers Attitudes and Knowledge Scale (LAKS). Knowledge and attitudes toward helping someone who experiences suicide risk were assessed via the LAKS (Snep, 1992), a 25-item self-report inventory. Each item was rated on a Likert scale ranging from 1 (strongly agree) to 5 (strongly disagree); reverse coding was required for 22 of the 25 items. Thus, possible inventory scores ranged from 25 to 125 whereby higher scores were indicative of positive responses in the direction of the construct being assessed. Higher scores reflected increased knowledge and attitudes about everyday life events and social issues that face adolescents. Example items include "I can see when kids are having a hard time with other kids" and "If I respond properly, I can help someone who is thinking about suicide." Although Snep (1992) did not report reliability data, alpha = .80 for both the pretest and posttest scales in the current sample.

Rosenberg Self-Esteem scale (RSE). Self-esteem was measured via the RSE (Rosenberg, 1965) which assessed responses to statements of self-worth and distinguished among individuals with low and high esteem. The RSE is a 10-item instrument rated on a Likert scale that ranges from 1 (strongly agree) to 4 (strongly disagree); 5 items were reverse coded. Higher scores are indicative of higher self-esteem with possible scores ranging from 10 to 40. Example items include "On the whole, I am satisfied with myself" (reverse scored" and "I feel I do not have much to be proud of." This scale was originally normed on 5,024 high school juniors and seniors with reported scalability of .72. In this sample, for the pretest and posttests, alpha = .90 and .86, respectively.

Self Acceptance Scale (SCS). Self-acceptance or a sense of self-reliance on one's values and faith in one's capacity to cope with life was assessed via the SAS (Berger, 1952, 1955). It is a 36-item Likert scale in which scores range from 1 (completely true) to 5 (completely false) which yields a total score range of 36 to 180; 8 items were reverse coded. Respondents are asked to indicate how true or how false a statement is for them. Example items include "I'm afraid for people to find out what I'm really like for fear they'd be disappointed in me" and "I don't question my worth as a person, even if I think others do." Higher scores indicate strong beliefs of self-acceptance. In this sample, alpha = .94 on the prestest data and .91 on the posttest data.


The university's Institutional Review Board approved the present study. Students attending the LifeSavers weekend training program were administered the pre-test packet immediately upon arrival at the training site (T1). To insure confidentiality, participants determined a 4-digit number associated with the telephone number of their choice (i.e., home, mobile) as an identifier for all materials. At the end of the LifeSavers weekend training program (T2), students were given the posttest packet, which replicated the pre-test instruments, and asked to complete the packet on site. Approximately 30 minutes were required to complete the questionnaire. Students were informed that participation in the study was voluntary and that participation did not affect their training or status in the LifeSavers program. All trainees agreed to participate in the current study.


All participants completed T1 and T2 measures. The majority of participants (78%) were female; see Table 1. Mean age for the sample was 15.05 years (SD = .83; range 14-17). Though participants were enrolled in grades 9-12, most of them reported 10th grade status. The majority (65.1%) of participants' parents were said to be married.

A paired-samples t test was conducted to evaluate participants' pretest (T1) scores relative to post-training (T2) performance on measures of attitudes and knowledge, self-esteem, and self-acceptance. All pretest and post-test means, standard deviations, and effect sizes are presented in Table 2. Results indicated that attitudes and knowledge and self-esteem increased significantly with a large effect observed for the increase in self-reported attitudes and knowledge. However, the increase in scores from T1 to T2 was not significant for self-acceptance.


Fatal suicide attempts are a leading cause of death among youth age 13-19 years. Opportunities to intervene early are important and discourage the development of "suicidal careers" in which individuals at risk experience multiple suicide attempts, parasuicidal behavior, and persistent suicide ideation. Unfortunately, empirical support for teenage suicide prevention has not evolved much across U.S. communities. In the current study, we assessed knowledge and attitudes, self-acceptance, and self-esteem for high school students who participated in LifeSavers training, a suicide and crisis prevention program that has been implemented in several non-metropolitan communities. We found that youth who participated in the LifeSavers program increased in two of the three areas of measure--attitudes and knowledge and also self-esteem. This study makes an important contribution to the suicide literature in that it explores prevention for youth in non-metropolitan communities where suicide deaths are most rampant. This study also addresses the need for prevention research to go beyond death rates to address quality of life for troubled youth in rural environments.

Emphasis on mediating factors is worthwhile for the overall prevention of emotional crises among high school youth. The impact of LifeSavers training may speak to, at least in part, Durkheim's anomie such that LifeSavers trainees experience an increased sense of social cohesion and an atmosphere that discourages hopelessness and promotes a positive affect overall. Future studies should continue to consider mediating factors to understand the mechanism by which prevention programming functions. In this sample, we found that the LifeSavers training program seems to be efficacious for high school youth, particularly young women, in rural communities. Studies have indicated that those who report more proficiency for an activity are more likely to engage in that activity. Thus, increased self-esteem and also self-acceptance are important intermediate factors along with relevant knowledge associated with suicide risk. Future studies might consider other intermediate factors such as personality (extroversion v. introversion) and verbal acuity in suicide prevention that might facilitate peer support and helping behavior.

Though this study makes an important contribution to the suicide prevention literature, it is not without limitations. There was no random assignment to a control group to account for maturation or other effects of the retreat setting. Unfortunately, such studies are not often feasible in naturalistic conditions. Also, given the relatively short pre- and post-training interval, we do not know if the training effect was maintained. It is notable that most participants received some level of "booster" or continued training in their respective high schools and at varying rates. Some trainees participated in weekly activities that were led by an adult advisor. However, training activities were less frequent in some schools and individual LifeSavers trainees participated to varying degrees. Future studies would benefit from a waitlisted control group and statistical control for the wide range of continued training to which participants are exposed post-training. Another limitation of the study is the under-representation of male participants. Though adolescent girls are more likely to engage in self-harm behavior, boys are more likely to die by suicide. Thus, balanced attention to the needs of both boys and girls is warranted and recruitment of adolescent boys for ongoing peer support training is essential. Finally, there is no current evidence of behavior change that is associated with increase in knowledge or self-esteem. However, we posit that youth who are more knowledgeable about suicide risk and who are equipped to be good listeners are also more likely to provide more informed peer support in the event of a potential crisis.

In all, this study has important implications for adolescents and the communities in which they reside. Youth who are at risk for mental health problems typically do not get help until later in life (Patel, Fisher, Hetrick, & McGorry, 2007). However, peer support can have direct and indirect effects on potentially high-risk suicidal persons. Thus, primary prevention efforts, which dissuade generation of self-harm behavior, are critical and should be implemented in communities and after-school settings. Universal crisis prevention programs create a normative environment in which youth who have relatively little access to psychiatric services develop a sense of belonging that is reinforced with a readiness to seek help if needed. A climate that normalizes asking questions and listening to a distressed other can provide a welcome alternative to acting out in response to interpersonal problems with family and romantic relationships.

To our knowledge, this is the first empirical study to address youth suicide prevention in non-metropolitan communities. Programs such as LifeSavers potentially circumvent the critique that rural students are less informed about suicide (Adcock, Nagy, & Simpson, 1991).

Though school gatekeeping efforts have received some attention in the literature, added efforts toward creating a cultural milieu of peer support particularly in underresourced communities will significantly advance suicide prevention.


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Rheeda L. Walker and Olivia D. Hoskins, Department of Psychology, Southern Illinois University.

Judy Ashby, LifeSavers Training Corporation.

Farrah N. Greene, Department of Psychology, University of Hawaii at Manoa.

(1) The U.S. Office of Management and Budget (2000), which is responsible for urban and rural (now known as metropolitan and non-metropolitan) classification, assesses "degree of urbanization and adjacency to a metropolitan area". Groupings 1-9 were assessed by the OMB as of 2003 such that 1-3 are metropolitan and 4-9 are non-metropolitan. A code description of one describes counties in metropolitan areas with a population of one million or more whereas a code of nine describes a county that is completely rural or less than 2,500 people in an urban population that is not adjacent to a metropolitan area. The U.S. Department of Agriculture (2004) only codes urban and rural areas on the county level for population, urbanization and proximity to metropolitan areas and not by the characteristics of an individual city or town.

Requests for reprints should be sent to Dr. Rheeda Walker, Department of Psychology, University of Georgia, Athens, GA 30602-8048. E-mail:
Table 1. Demographic characteristics of participants.

Characteristic n %

 Female 49 77.8
 Male 14 22.2

 9 24 38.1
 10 34 54.0
 11 4 6.3
 12 1 1.6

Parent's marital status
 Married 41 65.1
 Separated 4 6.0
 Divorced 3 4.8
 Remarried 11 17.5
 Deceased 2 3.2

Table 2. Pre-test and post training comparisons and effect sizes.

 Pre-test Post-test t(df) Cohen's
 M(SD) M(SD) d

Attitudes and
Knowledge 97.44 (7.32) 103.72 (7.58) 6.13(53) ** .85

Self-acceptance 128.47 (21.93) 130.74 (23.21) 1.21 (52) .10

Self-esteem 29.65 (5.03) 31.38 (5.30) 3.76 (59) ** .34

** p<.001
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Author:Walker, Rheeda L.; Ashby, Judy; Hoskins, Olivia D.; Greene, Farrah N.
Article Type:Report
Geographic Code:1USA
Date:Jun 22, 2009
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