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Suicide prevention remains challenging among youth, as many do not disclose suicidal ideation. Nearly one-third of American Indian and Alaska Native (AI and AN, tribal, or native) youth see concerning messages on social media at least weekly.
To prepare adults to support AI and AN youth who post or view concerning messages, our team designed an hour-long training: Responding to Concerning Posts on Social Media. This study tested the usability, appeal, and impact of the training.
A purposive sample of 70 adults was recruited to participate in the pilot, which included 2 study arms. Arm 1 participants completed a 30-min training video and reviewed accompanying handouts, including the Viewer Care Plan (VCP). The VCP provided a 3-step planning and response tool: (1) Start the Conversation, (2) Listen, Gather Information, and Assess Viewer Experience, and (3) Plan and Act. The intent of the VCP was to support and connect AI and AN youth who either view or post concerning messages on social media to life-saving resources. Those enrolled in arm 2 participated in an additional interactive role-play scenario with a coach that took place after the training, via text message. Participants provided qualitative and quantitative feedback on the training’s relevance, appeal, and utility. Paired
Altogether, 35 participants finished the training and completed pre- and postsurveys; 22 participants completed the 6-month follow-up survey. Pre-post analyses of differences in means found significant improvement across several efficacy measures, including confidence starting a conversation about social media (
Findings indicate that the Responding to Concerning Posts on Social Media training is a promising tool to prepare adults to intervene and complete the VCP. Additional evaluation with a larger cohort of participants is needed to determine the unique impact of the role-play scenario and changes in mental health referral rates, behaviors, and skills.
According to the Center for Native American Youth, suicide prevention remains one of the most daunting challenges for American Indian and Alaska Native (AI and AN, tribal, or native) communities [
Emerging research has found that some at-risk youth disclose depression symptoms and suicidal ideation on social media channels, including Facebook, Twitter, and Instagram [
Social media is used frequently by the majority of AI and AN youth (aged 10-24 years) [
Social media connections between youth and adults, such as college students, are increasingly common [
Despite the frequency of such concerning posts on social media and the willingness of youth to discuss this content with a known adult, formative research with tribal health educators across the United States found that less than 5% felt adequately prepared to address concerning social media posts [
The three primary learning objectives for the training were to prepare adults who work with Native youth to (1) identify youth who witness concerning social media posts, letting them know they need not respond alone, (2) assess those who see concerning posts and address their concerns, frustration, or fatigue, and (3) confidently implement the
The
The Web-based training session was created using Articulate 360 software by Articulate Global, a comprehensive e-learning platform that allows for the creation of responsive and interactive Web-based trainings. The 1-hour Web-based training engaged participants through a self-paced training addressing the three learning objectives. The video included voiced-over narration through slides, which was also available as a readable transcript. The Web-based training session included 9 modules: (1) Welcome, (2) What are concerning posts? (3) Who is this training for? (4) Training goals and overview, (5) 30-minute video training, (6) Training handouts, (7) Community awareness activities, (8) Final review, and (9) A reminder for self-care.
Interactive slides were embedded throughout the Web-based training session to provide opportunities for reflection. The training was self-paced and could be advanced by clicking the
Participants were instructed that, under the
Midway through the Web-based training session, participants viewed a 30-minute video. The video provided an overview of why concerning posts should be taken seriously and shared findings from focus groups with Native youth about their experience seeing and responding to concerning posts on social media. The video included interviews with a Native family, who is from an AI background, and lost a child by suicide. In addition, the video included interviews with mental health professionals, who shared tips and examples for how to support youth and the community.
The video introduced the
Step 1 - Start the Conversation: Normalize the topic at community gatherings and school events to raise awareness about concerning posts on social media. Let youth know they can come to you for help, as a trusted adult.
Step 2 - Listen, Gather Information, and Assess Viewer Experience: If a youth approaches you, praise their efforts to help and assess their well-being. Let them know it can be scary or frustrating to repeatedly see concerning messages. Then, gather information from the viewer. What have they already tried? Who posted the message? How well do you know them? Do you know any trusted adults for the youth who posted the message?
Step 3 - Plan and Act: Reassure the youth that you will take it from here. If you are comfortable contacting the person who posted the concerning message, use the question, persuade, refer (Question, Persuade, and Refer [QPR]) suicide intervention model. If you would prefer not to, contact another trusted adult to create an appropriate response plan.
The video stressed the importance of adults identifying themselves as trusted adults in the community whom youth can ask for help from.
The Web-based training session concluded with an overview of the training handouts. These included a two-page summary of concerning posts, examples of concerning messages provided by youth during focus groups, and tips for talking about suicidality; a one-page VCP flyer and tip card; a QPR Institute training flyer to encourage folks to seek additional suicide prevention training; Kognito Web-based role-play simulations to prepare individuals to lead real-life conversations that change lives (free to tribes); a #WeAreConnected suicide prevention rack card; a bullying prevention brochure; and a cyberbullying prevention brochure.
After completing the Web-based training session, a subset of participants was invited to participate in a coached role-play scenario. The goal of the role-play was to test and improve participants’ skills as they implemented steps in the VCP. During the role-play, the research team played the part of a youth who had seen a concerning social media post and was reaching out to the participant as a trusted adult for help responding to the post. If the participant forgot or skipped steps during the interaction, the research team offered prompts related to important skills in the VCP (
At the end of the interaction, participants were emailed a 3-minute video clip of an exemplar role-play scenario, modeling complete, successful use of the VCP.
Ideal responses and coaching prompts provided during the role-play scenario.
Viewer care plan skill | Ideal response | Coaching prompt |
Hi I’m so glad you’re reaching out. Thank you, you are so brave. It can be difficult to know what to do with concerning posts. It’s great that you noticed and reached out to me. |
I’m feeling pretty scared and confused. I’m not sure if I should just ignore it, or what. What if they do something, then I’d feel awful. Honestly, this is freaking me out. I want to say something, but just don’t know what. |
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Have you said or done anything yet in response to the post? Did you like it? Share it? Message them? Have you seen this person posting like this behavior? Is this common for them? |
I direct messaged them like 5 times, texted ‘em, and they continue to post depressing stuff I’m over it, I think I’m just going to delete them from my FB. I tried reporting it to Facebook, but it didn’t seem like they did anything-it’s stressing me out. I don’t know who to trust, so I haven’t told anybody. |
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Can you tell me a little more about the person who’s posting this content? Is the person posting this a friend, acquaintance, or somebody you know? Do you know any adults or trusted friends who could help this person? |
I don’t know if it matters, but I’m like not really good friends with them or anything. I don’t really know them or talk to them in person, but I know their coach from school. Should I tell them? |
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You did the right thing by reaching out. I will take it from here. You gave me enough information to follow up with their coach. I will take it from here. We won’t mention your name, they don’t need to know that. So you can feel assured that your privacy will be kept. |
Are you going to tell anybody I told you? If ok, I’d like to just keep it between you and I. So, what should I do now? Are you going to reach out to them? I think you’d be way better at knowing what to do than me. |
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Are you feeling ok about the situation now that we’ve had the conversation? I want to give you a few resources if you want to learn more about this topic: link to WRNa. Facebook also has a tool: link that you can report concerning posts. Again, thank you for reaching out and always know that you can reach out to me. I won’t share your name with anyone else. |
If this happens again, are there any places that could help me respond? Isn’t there something on Facebook that I can use to report the post and FB can help them out? I’m not sure if I feel comfortable reaching out if I see this again. Is there something else I can do? |
aWRN: We R Native.
The study protocol was reviewed and approved by the Seattle Children’s Research Institute Institutional Review Board (IRB) and the Portland Area Indian Health Service IRB. Data collection took place between December 2016 and January 2018.
The Northwest Portland Area Indian Health Board recruited participants over a 2-month period using an online recruitment letter that described the training objectives and eligibility criteria. The form was distributed using a Constant Contact listserv and email listserv that reaches over 750 tribal health educators and adolescent health allies across the United States. Those interested in participating were directed to a SurveyMonkey link that confirmed eligibility criteria, followed by an electronic consent form, and a form to collect participant demographics. Demographics collected at this point included: name, tribe, organizational affiliation, state, number of years working with AI and AN youth, types and amount of suicide prevention training, and mailing address for US $15 incentive.
Interest forms were completed by 50 eligible educators living in the Pacific Northwest, including the States of OR, WA, ID, and by 23 educators living in other regions of the United States. Eligible participants included adults (≥18 years old) who mentored and/or regularly interacted with AI and AN youth. All participants indicated they had access to a computer with internet to complete pre-post surveys and watch the video and had access to a mobile phone that could be used to carry out the interactive role-play scenario. In appreciation for their time, participants received US $15 after completing the intervention and US $15 after completing the 6-month follow-up survey.
To begin the study, the research team sent participants a welcome email with a link to the Web-based training session and a reminder about using their unique identification. The training was available for participants to complete anytime during the 3-month window. Throughout the duration of the training period, the data manager checked for survey completion on a biweekly basis. Nonresponders were sent tailored reminders to complete the training and pre- and postsurveys up to four times over 3 months.
After completing the Web-based training session with 30-minute training video, participants were randomized using a blocked randomization process, into one of the two study arms (
To collect the 6-month follow-up data, the research team sent participants tailored reminders every 2 weeks, staggered by their training or role-play completion date, over a 3-month period.
Completed 1-hour webinar, including 30-minute video training
Reviewed training handouts
Immediate follow-up survey
Six-month follow-up survey
Completed 1-hour webinar, including 30-minute video training
Reviewed training handouts
Immediate follow-up survey
Participated in coached role-play via text message
Viewed 3-minute video clip of an exemplar role-play scenario
Six-month follow-up survey
The pre-, post-, and 6-month follow-up survey tools were collaboratively designed by the two research teams. The key outcome measures for the training were changes in concerning post knowledge, intention to intervene, and self-efficacy associated with steps in the VCP. The surveys were collected electronically using Catalyst software. Catalyst is the secure, Web-based survey design and collection software used by the University of Washington and Seattle Children’s Research Institute. The software is approved by the University of Washington IRB and can be configured not to collect respondent IP addresses. Pre- and postsurveys were collected and managed using Catalyst.
The research team randomized eligible participants using three variables (previous suicide prevention training experience, current job role, and self-efficacy), using a cluster randomization by groups, into two study arms. Participants in arm 1 watched the 30-minute training video and reviewed accompanying handouts. Those enrolled in arm 2 watched the 30-minute training video, reviewed the training handouts, and participated in an interactive role-play with a coach that took place after the training, via text message.
The presurvey collected participant demographics, including gender, age, state of residence, race and ethnicity, and role in their organization or community. Demographic variables were summarized in terms of frequencies and percentages.
The post survey included three quantitative measures of intervention usability and appeal, including (1) rate the quality of the training video (scale 0-6), (2) rate the quality of the training handouts (scale 0-6), and (3) would you recommend the training to others (yes, no)? At the end of the survey, participants were also asked to provide open-ended feedback on the (1) 1-hour webinar, (2) 30-minute video, (3) the training handouts, (4) a 30-minute coached role-play scenario, (5) the most valuable concepts or skills they acquired during the training, and (6) other ideas or suggestions to improve the training. The team synthesized open-ended responses to identify reoccurring themes.
The postsurvey included two quantitative measures assessing the coached role-play: (1) rate the quality of the coached role-play (scale 0-6), and (2) whether the coached role-play improved the training experience for the participant (yes, no). The investigators also conducted a content analysis of the coached role-play transcripts to evaluate participant adherence to the three steps of the VCP. A total of two trained coders developed a codebook to determine adherence to recommended VCP communication strategies. The research team then viewed the categories and coding system to verify consistency and accuracy, before coding took place. Responses were then analyzed across all role-play participants. The team also synthesized open-ended responses to survey questions, to identify reoccurring themes.
Analysis of measures of effectiveness included paired
All survey outcome variables were summarized in terms of means and standard deviations. Absolute changes between pre- versus postintervention were calculated and evaluated using a paired
A total of two researchers conducted content analysis on the role-play transcripts to assess participants’ adherence to the skills and strategies recommended in the VCP. In addition, the conversational style of each participant was evaluated. To address adherence to the VCP, two trained investigators used a deductive approach in which the VCP informed
To evaluate conversational styles, the two researchers used an inductive, open coding technique. An initial review of transcripts led to the development of categories informed by the data. The researchers used an iterative process of reviewing transcripts and refining the codebook until the categories were finalized, resulting in three categories. The first was Directive, in which the participant used an authoritative tone, giving instructions to the youth. The second was Collaborative, in which the participant sought consensus about a plan of action. The third was Noninclusive, in which the participant suggested a plan of action that did not involve the youth. Conversational styles were not mutually exclusive; some participants used more than one. For both content analysis techniques, interrater agreement was calculated using a 20% subsample of transcripts. For Assess Well-being of the Viewer and Gather Information, agreement was 88%. For all other variables, agreement was 100%.
Eligible prospective participants (N=73) included teachers, coaches, counselors, and tribal health personnel (personnel working with tribal communities), with varying levels of experience responding to someone with suicidal ideation. Most interest form applicants reported having 10 or more years of experience working with Native youth (41/73, 56%), followed by 1 to 5 years (16/73, 22%). Most reported using social media themselves on a daily basis (61/73, 84%) or weekly basis (8/73, 11%). Nearly one-third (22/73, 30%) reported having no formal training in suicide prevention or intervention skills; the remainder identified one or more trainings, including QPR (27/73, 37%), ASIST (27/73, 37%), Kognito (1/73, 1%), SafeTALK (11/73, 15%), Youth Mental Health First Aid (14/73, 19%), or Sources of Strength (2/73, 3%).
The blocked randomization process balanced the two arms in relation to experience working with AI and AN youth, experience using social media, and prior training in suicide prevention. Those who participated in the intervention and completed pre- and postsurveys were primarily female (64/73, 88%) and reported working in youth wellness or prevention; participants also included parents, coaches, teachers, and mental health professionals (
Demographic information for tribal health educator participants.
Demographics | All participants (n=41) | Participants who completed pre- and postsurvey (n=35) | Participants who completed, pre-, post-, and 6-month survey (n=22) | ||||
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Male | 5 (12) | 5 (14) | 4 (18) | |||
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Female | 36 (88) | 30 (87) | 18 (81) | |||
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Teacher or educator | 8 (20) | 7 (20) | 6 (27) | |||
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Coach | 4 (10) | 4 (11) | 3 (14) | |||
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Youth wellness or prevention staff | 20 (49) | 20 (57) | 14 (64) | |||
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Nurse or clinician | 2 (5) | 2 (6) | 3 (14) | |||
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Mental health professional | 6 (15) | 6 (17) | 5 (23) | |||
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Parent | 7 (17) | 6 (17) | 4 (18) | |||
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Other | 19 (39) | 16 (46) | 8 (36) |
The immediate postsurvey was completed by 85% (35/41) of participants; the 6-month follow-up was completed by 71% (29/41). Almost half of the eligible participants completed the training intervention associated with their study arm (arm 1: 17/33, 52%; arm 2: 12/35, 34%), and 43% (29/67) completed the 6-month follow-up survey (arm 1: 17/33, 52%; arm 2: 12/35, 34%).
On a 7-point Likert scale (rating 0 as poor and 6 as excellent), participants gave the training video an average score of 5.32 (SD 0.78) and the handouts a score of 5.27 (SD 1.12); all participants indicated they would recommend the training to others.
When asked for open-ended feedback on the training, participants were enthusiastic about its utility and expressed they would recommend it to their peers:
I think the video was VERY well done! The personal experiences in the beginning with the Lukes family really engaged me and brought the severity of the topic home.
I thought it was really good and would like to be able to use it for trainings of others and referral for people. I am a mental health practitioner suicide prevention, intervention, and postvention, and think it would be a valuable tool for me. Good job!
Many offered helpful suggestions to improve the training materials:
The second half of the video could be expanded, to include more focus on Ask About Suicide (ASK) and QPR. Instead they were referred to and mentioned.
Perhaps if a video was made that demonstrated the roleplay (like the one we did on the phone). That was really, really beneficial.
Include additional visuals of emojis and statements used by youth.
Others gave suggestions to support its dissemination in community settings:
Adapt the video for community presentations to educate parents and para-professionals.
Six months after participating in the training, nearly all participants reported benefiting from the training and following its recommendations:
This training is excellent, especially for adults working with youth in contexts beyond social services. Being in Indian County involves many social, economic, educational, and recreational contexts. It is good that it offers training for people to effectively and proactively support our Native youth.
The training was a great tool and discussion starter for folks in our community when I brought up the topic.
Our pilot evaluation of the effectiveness of the training included positive changes across several measures. A significant positive change was noted across all measures of confidence, including confidence starting a conversation with a youth about concerning posts on social media, intervening when a youth witnesses a concerning post by a family member or acquaintance, and confidence recommending support services to youth who have witnessed or posted a concerning message. Finally, participants reported improved confidence referring an at-risk youth to mental health services. In all cases, the difference of means between pre- and postsurvey was statistically significant, as noted in
Comparison of training effectiveness between pre- versus postintervention.
Variable | Preintervention, mean (SD) | Postintervention, mean (SD) | Change from pre- to postintervention, mean difference (SD) | |
Difficulty supporting youth posting CSMMa | 1.54 (1.62) | 1.31 (1.32) | 0.2286 (1.66) | .42 |
Difficulty supporting youth who saw CSMM | 1.31 (1.47) | 1.03 (1.27) | 0.2857 (1.69) | .32 |
Confidence starting a conversation with youth about CSMM | 4.09 (1.92) | 5.17 (0.98) | −1.0857 (2.01) | .003b |
Confidence intervening effectively when a youth witnesses CSMM by their families or friends | 3.63 (1.99) | 5.2 (0.96) | −1.5714 (1.99) | <.001b |
Confidence intervening effectively when a youth witnesses CSMM by their acquaintance | 3.29 (1.99) | 4.94 (1.19) | −1.6571 (2.01) | <.001b |
Confidence recommending support services to a youth who witnesses CSMM | 4.06 (2.06) | 5.43 (0.74) | −1.3714 (2.13) | <.001b |
Confidence recommending support services to a youth who has posted CSMM | 4.37 (1.9) | 5.54 (0.66) | −1.1714 (1.99) | .001b |
Confidence referring a poster of CSMM to a mental health professional within community | 4.06 (1.89) | 5.34 (0.76) | −1.2857 (1.71) | <.001b |
aCSMM: concerning social media message.
bStatistically significant difference.
At the 6-month follow-up, we again identified positive changes in relation to the presurvey. These included sustained positive findings regarding contacting youth who posted concerning messages, confidence starting conversations with youth about concerning social media posts, confidence intervening when a youth witnessed a concerning post, and confidence referring youth who posted or witnessed concerning posts to a mental health provider. Furthermore, there were statistically significant increases in self-reported behavior, including bringing up concerning posts with youth and adults in their community. Each of these changes were significant, as noted in
Comparison of self-reported behavior from pre- to 6 months postintervention.
Variable | Preintervention, mean (SD) | 6-month follow-up, mean (SD) | Change from preintervention to 6-month follow-up, mean difference (SD) | |
In the last 6 months, how many times have you brought up CSMMa with youth in your community? | 0.89 (0.87) | 1.39 (0.86) | −0.5000 (0.86) | .007b |
In the last 6 months, how many times have you brought up CSMM with adults in your community? | 1.04 (0.83) | 1.58 (0.99) | −0.5385 (1.10) | .02b |
What percentage of youth believe it is appropriate to intervene when some posts CSMM? | 4.58 (2.89) | 5.66 (2.25) | −1.0769 (2.62) | .047b |
What percentage of adults believe it is appropriate to intervene when some posts CSMM? | 5.89 (3.22) | 6.77 (2.56) | −0.8846 (2.72) | .11 |
Confidence contacting a poster of CSMM to assess their risk | 3.74 (1.76) | 5.12 (0.96) | −1.3846 (1.75) | <.001b |
In the last 6 months, how many times have you intervened when a youth witnessed CSMM? | 1.24 (1.76) | 0.74 (0.73) | 0.5000 (1.58) | .12 |
In the last 6 months, how many times have you recommended support services to youth when they witnessed CSMM? | 2.58 (3.73) | 0.93 (0.98) | 1.6538 (3.38) | .02b |
In the last 6 months, how many times have you referred support services to youth when they posted CSMM? | 1.77 (3.15) | 0.74 (0.83) | 1.0385 (2.66) | .06 |
Difficulty supporting youth posting CSMM | 1.58 (1.63) | 1.31 (1.65) | 0.2692 (2.15) | .53 |
Difficulty supporting youth who saw CSMM | 1.24 (1.46) | 1.00 (1.55) | 0.2308 (2.10) | .58 |
Confidence starting a conversation with youth about CSMM | 4.27 (1.72) | 5.43 (0.81) | −1.1538 (1.78) | .003b |
Confidence intervening effectively when a youth witnesses CSMM by their families or friends | 3.93 (1.94) | 5.43 (0.81) | −1.5000 (2.01) | <.001b |
Confidence intervening effectively when a youth witnesses CSMM by their acquaintance | 3.62 (2.03) | 5.00 (1.17) | −1.3846 (2.00) | .001b |
Confidence recommending support services to a youth who witnesses CSMM | 4.31 (1.83) | 5.50 (0.77) | −1.1923 (1.79) | .002b |
Confidence recommending support services to a youth who has posted CSMM | 4.54 (1.78) | 5.58 (0.71) | −1.0385 (1.68) | .004b |
Confidence referring a poster of CSMM to a mental health professional within community | 4.35 (1.81) | 5.54 (0.71) | −1.1923 (1.72) | .002b |
aCSMM: concerning social media message.
bStatistically significant difference.
Among arm 2 participants, 18 completed the coached role-play, and they gave this training component an average rating of 5.38 (SD 1.02). All reported the role-play improved their training experience. Evaluation of the role-play transcripts found that participants followed some of the VCP guidelines more than others. All participants completed the
A total of three main response styles emerged: Collaborative (11/18, 61%), Directive (8/18, 44%), and Noninclusive (4/18, 22%), with 22% (4/18) of health educators using more than one approach. Collaborative approaches included shared decision-making processes and questions posed to youth confirming their support for a given follow-up plan. For example, one participant asked, “Would you feel comfortable approaching her B-ball coach…about the posts?” Directive approaches, by contrast, involved instructions given to the youth about how to proceed. An example of Directive message was, “Please be sure to contact an adult to support you—and check back in with me.” Finally, when using Noninclusive approaches, participants informed youth of next steps the adult participant would be taking without consensus seeking. One participant said, “I'll take care of following up and I'll talk to the coach or someone else who can help.”
This study assessed the usability, appeal, and impact of an hour-long training to prepare adults who work with Native youth to better support teens who post or view concerning messages on social media. Three major findings emerged in addressing this study purpose. First, participants provided feedback that included positive reception of the training. Second, findings supported positive effects of the training on participants’ self-efficacy to address concerning social media posts. Third, analysis of the coached role-plays yielded opportunities for intervention improvements.
Our first major finding was that participants largely regarded the training intervention positively. After completing the training, participants expressed enthusiasm about its content and utility; 100% indicated they would recommend the training to their peers. Participants also offered helpful suggestions to improve the training materials, which have since been used to make updates and enhancements to the webinar, video, and handouts. These findings support the usability and appeal of the intervention.
Our second major finding was that significant improvements were noted across several measures of training efficacy that were retained even at 6 months, including contacting youth who had posted concerning messages, confidence starting conversations with youth, confidence intervening when a youth witnessed a concerning post, and confidence referring youth to a mental health provider. Most importantly, participants reported an increased number of clinical referrals 6 months posttraining, an important marker of training efficacy. These findings are consistent with previous studies using training as an intervention strategy. Previous studies supported Web-based gatekeeper trainings as effective suicide prevention approaches, particularly among adults serving AI and AN communities [
Our third main finding was that evaluation of the coached role-play revealed opportunities to improve the training intervention. As in our study, previous research has included a role-play component in gatekeeper trainings to prevent suicide [
Further, analysis of the coached role-play revealed three communication styles when responding to youth who had viewed concerning posts: Collaborative, Directive, and Noninclusive. One possible explanation for the emergence of these three techniques is professional role and training. For example, a physical education teacher or coach may approach a conversation about a concerning social media post in a collaborative manner to provide support and encourage rapport in absence of specific medical training, whereas a school nurse may be more directive, having training and resources at their fingertips. These findings are important to consider in light of previous research on approaches to conversations about sensitive social media posts. Some evidence suggests that college students have preferences about how to conduct conversations related to concerning social media content [
Since the completion of the study, the training has been made available to tribal health educators at Healthy Native Youth website [
Several important limitations were present in our study design. This study did not involve a control group and, as such, cannot determine the true effectiveness of the training intervention. The opt-in recruitment strategy also limits the generalizability of our findings, as those who agreed to participate are likely more aware of the importance of this topic than other adults who chose not to participate. In addition, our initial sample size was small; only 85% of participants completed the immediate postsurvey, and just over half of them completed the 6-month follow-up survey. This may have reflected a response bias among our respondents. In a more robust study design, special attention should be given to improve survey response rates and participant retention, especially if conducted over a longer period of follow-up.
Findings from this pilot study indicate that the
American Indian
Alaska Native
Institutional Review Board
question, persuade, refer
Substance Abuse and Mental Health Services Administration
Viewer Care Plan
This study was funded, in part, by Garret Lee Smith grant number SM061780 from the Substance Abuse and Mental Health Services Administration (SAMHSA). The views, opinions, and content of this publication are those of the authors and contributors and do not necessarily reflect the views, opinions, or policies of Center for Mental Health Services, SAMHSA, or Health and Human Services and should not be construed as such.
None declared.