Diffusion of a Peer-Led Suicide Preventive Intervention Through School-Based Student Peer and Adult Networks

Abstract

Background: Peer-led interventions have been applied to prevent various health behavior problems and may be an important complement to individual-level suicide prevention approaches. Sources of Strength trains student "peer leaders" in secondary schools to conduct prevention activities that encourage other students to build healthy social bonds and strengthen help-seeking norms. Prior work examining diffusion of peer-led programs has focused on youths' closeness to peer leaders but minimally on other factors such as connections to adults and suicidal behavior. Methods: We examined implementation and dissemination of Sources of Strength in 20 schools. Over 1 year 533 students were trained as peer leaders and 3,730 9th-12th graders completed baseline surveys assessing friendships and adults at school, and suicidal thoughts/behaviors; and end-of-year surveys reporting intervention exposure: viewed poster/video, attended presentation, direct peer communication, and activity participation. Chi-square tests compared exposure rates by student and network characteristics. Multi-level logistic regression models tested predictors of exposure across individual and school-level characteristics. Results: Exposure to the intervention varied greatly by school and by individual student characteristics and network position. Training more peer leaders increased school-wide exposure for all modalities except presentation (Bs 0.06-0.10, p's < 0.05). In multivariate models, exposure was consistently higher for students closer to peer leaders in the friendship network (ORs 1.13-1.54, p's < 0.05) and students who named more trusted adults (ORs 1.08-1.16, p's < 0.001); and lower for males (ORs 0.56-0.83, p's < 0.05). In multivariate models, training more students as peer leaders predicted exposure to poster-video and direct peer communication in larger schools (OR = 3.34 and 2.87, respectively). Network characteristics influenced exposure similarly for students with suicidal thoughts and behaviors. Discussion: Our findings confirm prior work showing the importance of personal affiliations to peer leaders and natural networks as a medium for diffusion of peer-led prevention efforts. We build on that work by showing independent effects of closeness to adults at school and number of peer leaders trained. There is a need to strategically select peer leaders to maximize closeness to students school-wide, particularly in larger schools. Additional work is required for Sources of Strength to devise messaging strategies to engage males and students isolated from adults at school.

Keywords: diffusion of innovations; peer leaders; peer messaging; school intervention; social connectedness; social networks; social support; suicide prevention.

Figure 1

Percent of school trained as a peer leader by school size. Nodes are labeled with total number of peer leaders.

Figure 2

School-wide intervention exposure by (A) steps to closest peer leader, (B) number of friends named, (C) number of trusted adults named, and (D) steps to closest peer leader, stratified by gender (female = solid lines, male = dashed lines). Error bars represent one standard error.

Figure 3

Exposure to the Sources of Strength intervention by percent peer leaders at school.

Figure 4

Comparison of two Sources of Strength exposures in a large school with few peer leaders. Nodes are colored by the distance to a peer leader. Large nodes have had exposure to the intervention through either a presentation (A) or direct peer communication (B). This school has one of the lowest percentages of students trained as peer leaders (3.2%) and consequently has a low peer communication rate (20.3%) but a modest presentation exposure (53.7%).

Figure 5

Two networks from schools of comparable sizes. Nodes are colored by the distance to a peer leader (A,C) or by number of trusted adults named (B,D). Large nodes have had direct peer communication while small nodes have not. School A is size 103 with 8.7% peer leaders and 52.0% peer communication exposure, while School B is size 73 with 31.3% peer leaders and 73.5% peer communication exposure.