Quality of Research
Documents Reviewed
The documents below were reviewed for Quality of Research. The research point of
contact can provide information regarding the studies reviewed and the availability
of additional materials, including those from more recent studies that may have been conducted.
Study 1Wyman, P. A., Brown, C. H., Inman, J., Cross, W., Schmeelk-Cone, K., Guo, J., et al. (2008). Randomized trial of a gatekeeper program for suicide prevention: 1-year impact on secondary school staff. Journal of Consulting and Clinical Psychology, 76(1), 104-115.  Study 2Matthieu, M. M., Cross, W., Batres, A. R., Flora, C. M., & Knox, K. L. (2008). Evaluation of gatekeeper training for suicide prevention in veterans. Archives of Suicide Research, 12(2), 148-154. Study 3Cross, W. F., Seaburn, D., Gibbs, D., Schmeelk-Cone, K., White, A. M., & Caine, E. D. (2011). Does practice make perfect? A randomized control trial of behavioral rehearsal on suicide prevention gatekeeper skills. Journal of Primary Prevention, 32(3-4), 195-211.
Outcomes
| Outcome 1: Knowledge about suicide |
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Description of Measures
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Two types of knowledge about suicide were assessed: declarative knowledge (i.e., knowledge of suicide-related principles presented in the QPR gatekeeper training) and perceived knowledge (i.e., a participant's perception of his or her own knowledge of a topic).
In all three studies, declarative knowledge about suicide was assessed with a measure that contained 14 items: 8 pertaining to appropriate QPR behaviors with individuals and 6 pertaining to suicide risk factors. Examples of items include "People who talk about suicide are only talking and should be ignored, since people who talk about suicide don't do it (circle true or false)" and "Asking a distressed person if he or she is having thoughts of death or suicide (circle one): (a) Should never be done, as it may put the idea of suicide in the person's mind; (b) Should only be done by professionally trained persons; (c) May lower the risk of suicide; or (d) Should have no effect on the risk for suicide." Each participant's score was determined as the percentage of correct responses, with higher scores indicating greater declarative knowledge about suicide.
In one study, perceived knowledge of suicide was assessed with a 9-item measure. Participants rated each item with a 7-point scale ranging from 1 (nothing) to 7 (very much). In the other two studies, perceived knowledge of suicide was assessed with a 5-item measure. Participants rated each item (e.g., "knowledge of warning signs of suicide") with a 5-point scale ranging from 0 (poor) to 4 (excellent). For both scales, higher scores indicate greater perceived knowledge of suicide.
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Key Findings
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In one study, 32 middle and high schools were randomly assigned to a group that received QPR gatekeeper training or to a wait-list control group. A random sample of staff from each school (i.e., teachers, administrators, health/social service staff, support staff) was identified prior to school randomization and followed for an average of 1 year after training. At the 1-year follow-up, school staff who received QPR gatekeeper training had higher declarative knowledge scores (p = .001) and higher perceived knowledge scores (p < .001) than staff from control schools, using intent-to-treat analyses and controlling for baseline levels. These findings were associated with small (Cohen's d = 0.41) and large (Cohen's d = 1.32) effect sizes, respectively.
In a second study, Department of Veterans Affairs (VA) staff, including clinical providers (e.g., psychologists, social workers) and nonclinical staff (e.g., administrative staff, community outreach workers), from a national program of 209 community-based VA counseling centers were offered QPR gatekeeper training during scheduled regional conferences. Immediately after QPR gatekeeper training, clinical providers and nonclinical staff had higher declarative knowledge scores (p < .0001) and higher perceived knowledge scores (p < .0001) relative to scores before training. These findings were associated with medium effect sizes (Cohen's d = 0.53 and 0.54, respectively).
In a third study, clinical school personnel (including mental health professionals) and nonclinical school personnel (including teachers and bus drivers), as well as parents who were participating in the school district's Safe Homes Project, were randomly assigned to receive QPR gatekeeper training or QPR gatekeeper training without behavioral rehearsal (i.e., without role-play practice). Nonclinical school personnel and parents in both training conditions had increases in declarative and perceived knowledge about suicide from before to after the training, and these levels of knowledge were maintained at the 3-month follow-up (p < .001 for each type of knowledge).
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Studies Measuring Outcome
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Study 1, Study 2, Study 3
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Study Designs
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Experimental, Preexperimental
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Quality of Research Rating
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2.6
(0.0-4.0 scale)
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| Outcome 2: Gatekeeper self-efficacy |
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Description of Measures
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In one study, gatekeeper self-efficacy was assessed with two measures. In one measure, participants used a 7-point scale ranging from "strongly disagree" to "strongly agree" to rate their level of agreement with 7 statements related to the gatekeeper role and their ability to identify and intervene with an individual at risk for suicide (e.g., "I can make appropriate referrals within my school for students contemplating suicide"). In a second measure, participants used a 7-point scale ranging from 1 (not prepared) to 7 (quite well prepared) to rate 8 items regarding their preparation to perform gatekeeper activities (e.g., "ask appropriate questions about suicide"). Higher scores on both measures indicated greater gatekeeper self-efficacy.
In the other two studies, gatekeeper self-efficacy was assessed with a measure composed of 5 items (e.g., "I feel confident that I can identify signs of emotional distress in students"), which participants rated on a 5-point Likert-type scale ranging from 0 (poor) to 4 (excellent). Higher scores indicated greater gatekeeper self-efficacy.
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Key Findings
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In one study, 32 middle and high schools were randomly assigned to a group that received QPR gatekeeper training or to a wait-list control group. A random sample of staff from each school (i.e., teachers, administrators, health/social service staff, support staff) was identified prior to school randomization and followed for an average of 1 year after training. At the 1-year follow-up, school staff who received QPR gatekeeper training had higher gatekeeper preparedness scores (p < .001) and higher gatekeeper efficacy scores (p < .001) than staff from control schools, using intent-to-treat analyses and controlling for baseline levels. These findings were associated with large effect sizes (Cohen's d = 1.21 and 1.22, respectively).
In a second study, Department of Veterans Affairs (VA) staff, including clinical providers (e.g., psychologists, social workers) and nonclinical staff (e.g., administrative staff, community outreach workers), from a national program of 209 community-based VA counseling centers were offered QPR gatekeeper training during scheduled regional conferences. Immediately after QPR gatekeeper training, all participants had higher gatekeeper self-efficacy scores (p < .0001) relative to scores before training. This finding was associated with a small effect size (Cohen's d = 0.49).
In a third study, clinical school personnel (including mental health professionals) and nonclinical school personnel (including teachers and bus drivers), as well as parents who were participating in the school district's Safe Homes Project, were randomly assigned to receive QPR gatekeeper training or QPR gatekeeper training without behavioral rehearsal (i.e., without role-play practice). Nonclinical school personnel and parents in both training conditions had an increase in gatekeeper self-efficacy from before to after the training, and this level of self-efficacy was maintained at the 3-month follow-up (p < .001).
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Studies Measuring Outcome
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Study 1, Study 2, Study 3
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Study Designs
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Experimental, Preexperimental
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Quality of Research Rating
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2.6
(0.0-4.0 scale)
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| Outcome 3: Knowledge of suicide prevention resources |
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Description of Measures
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Knowledge of suicide prevention resources was measured with 4 items:
- "Is there a specific plan for helping students who are contemplating suicide at your school?"
- "Are you familiar with your school's policies for helping students contemplating suicide?"
- "Are suicide prevention student education or resource materials (posters, brochures, etc.) available at your school?"
- "Do you feel you have adequate referral resources for students contemplating suicide at your school?"
Participants' responses to each item were coded as "no" (0) or "yes" (1) and averaged; higher mean scores indicate greater knowledge of suicide prevention resources.
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Key Findings
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Thirty-two middle and high schools were randomly assigned to a group that received QPR gatekeeper training or to a wait-list control group. A random sample of staff from each school (i.e., teachers, administrators, health/social service staff, support staff) was identified prior to school randomization and followed for an average of 1 year after training. At the 1-year follow-up, school staff who received QPR gatekeeper training had higher knowledge of suicide prevention resources scores (p < .001) than staff from control schools, using intent-to-treat analyses and controlling for baseline levels. This finding was associated with a large effect size (Cohen's d = 1.07).
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Studies Measuring Outcome
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Study 1
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Study Designs
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Experimental
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Quality of Research Rating
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2.9
(0.0-4.0 scale)
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| Outcome 4: Gatekeeper skills |
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Description of Measures
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Gatekeeper skills were assessed with the 5-item Observational Rating Scale of Gatekeeper Skills. The scale items compose four domains: General Communication (2 items: active listening and clarifying questions), Question (1 item: asking a direct question about suicide), Persuade (1 item: using convincing phrases), and Refer (1 item: making an appropriate referral). Using a 4-point scale ranging from 0 (indicating an absence of the skill) to 3 (indicating competent demonstration of the skill), a rater coded each domain item while watching a videotaped role-play interaction between a "school employee" or "parent," portrayed by the participant, and a "distressed youth," portrayed by a trained actor who followed a standardized protocol that increasingly signaled signs of distress covered in the QPR gatekeeper training. Each participant was given a brief, standardized backstory with the setting and details about the distressed youth. The participant was then instructed to converse naturally with the distressed youth for 5-10 minutes and respond to the best of his or her ability within the context of the given role. The item scores are combined for a Total Gatekeeper Skills score.
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Key Findings
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Clinical school personnel (including mental health professionals) and nonclinical school personnel (including teachers and bus drivers), as well as parents who were participating in the school district's Safe Homes Project, were randomly assigned to receive QPR gatekeeper training or QPR gatekeeper training without behavioral rehearsal (i.e., without role-play practice). Overall, all participants who received QPR gatekeeper training had higher Total Gatekeeper Skills scores (p < .05) and General Communication domain scores (p < .001) than the participants who received QPR gatekeeper training without behavioral rehearsal. However, from after the training to the 3-month follow-up, all participants in both training conditions had decreases in Total Gatekeeper Skills scores (p < .001), Question domain scores (p < .001), and Referral domain scores (p < .05).
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Studies Measuring Outcome
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Study 3
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Study Designs
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Experimental
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Quality of Research Rating
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2.8
(0.0-4.0 scale)
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| Outcome 5: Diffusion of gatekeeper training information |
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Description of Measures
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Diffusion of gatekeeper training information was assessed with 3 self-report items regarding the sharing of the training content and materials with others:
- "Did you discuss training with others? If so, with whom? What was the context of the discussion?"
- "Did you show the training materials to others? If so, to whom? Describe the context of the conversation."
- "Did you suggest to someone else that they may benefit from attending the training? What was the context of the conversation?"
Participants responded to each item at the 3-month follow-up.
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Key Findings
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Clinical school personnel (including mental health professionals) and nonclinical school personnel (including teachers and bus drivers), as well as parents who were participating in the school district's Safe Homes Project, were randomly assigned to receive QPR gatekeeper training or QPR gatekeeper training without behavioral rehearsal (i.e., without role-play practice). Findings from the 3-month follow-up indicated that almost all participants discussed the training with others, and about one-third recommended the training to others. In addition, a comparison of participants in each training condition indicated that more of the participants who received QPR gatekeeper training suggested training to at least one group (p < .05).
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Studies Measuring Outcome
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Study 3
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Study Designs
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Experimental
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Quality of Research Rating
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2.5
(0.0-4.0 scale)
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Study Populations
The following populations were identified in the studies reviewed for Quality of
Research.
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Study
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Age
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Gender
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Race/Ethnicity
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Study 1
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18-25 (Young adult)
26-55 (Adult)
55+ (Older adult)
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81.9% Female
18.1% Male
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84.5% White
11% Black or African American
2.5% Race/ethnicity unspecified
2% Hispanic or Latino
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Study 2
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18-25 (Young adult)
26-55 (Adult)
55+ (Older adult)
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63.3% Male
36.7% Female
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70.6% White
14.6% Black or African American
13.8% Hispanic or Latino
9.8% Race/ethnicity unspecified
2.5% Asian
1.8% American Indian or Alaska Native
0.7% Native Hawaiian or other Pacific Islander
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Study 3
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18-25 (Young adult)
26-55 (Adult)
55+ (Older adult)
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87% Female
13% Male
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93.5% White
5.3% Hispanic or Latino
1.8% Black or African American
1.2% American Indian or Alaska Native
1.2% Asian
1.2% Race/ethnicity unspecified
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Quality of Research Ratings by Criteria (0.0-4.0 scale)
External reviewers independently evaluate the Quality of Research for an intervention's
reported results using six criteria:
For more information about these criteria and the meaning of the ratings, see Quality of Research.
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Outcome
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Reliability
of Measures
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Validity
of Measures
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Fidelity
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Missing
Data/Attrition
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Confounding
Variables
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Data
Analysis
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Overall
Rating
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1: Knowledge about suicide
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2.3
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2.6
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2.5
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2.5
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2.7
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3.3
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2.6
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2: Gatekeeper self-efficacy
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2.3
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2.7
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2.5
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2.3
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2.7
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3.3
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2.6
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3: Knowledge of suicide prevention resources
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2.3
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2.8
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3.0
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2.5
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3.3
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3.5
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2.9
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4: Gatekeeper skills
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2.3
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2.3
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2.5
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2.5
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3.5
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3.5
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2.8
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5: Diffusion of gatekeeper training information
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1.5
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1.5
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2.5
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2.5
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3.5
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3.5
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2.5
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Study Strengths Measures demonstrated good internal reliability, as supported by Cronbach's alpha values. All measures appear to have face validity. Items measuring knowledge about suicide, gatekeeper self-efficacy, and knowledge of resources were identified as having content validity by an expert panel. In all three studies, the QPR gatekeeper training was conducted in a standardized manner by personnel with expertise in the training, who used a detailed manual, and with quality assurance procedures in place. A training checklist was also used to monitor fidelity. In one study, adherence of the actors to the script was rigorously measured and showed strong adherence, which did not drift over time. Although attrition was moderate in one study, there were no differences in the rates of attrition between the randomly assigned study groups, nor was attrition associated with any differences in the baseline measures; there was very little attrition in the other two studies. In all three studies, there were very few missing data, with the exception of the gatekeeper self-efficacy measure in one study. The randomized controlled design of two studies, with almost no baseline differences between groups, rules out a number of potential threats to internal validity. Data analytical procedures for all three studies were appropriate and thorough. The sample size and power were adequate to detect differences in the outcomes. One study used intent-to-treat and as-treated analyses.
Study Weaknesses There was inadequate interrater reliability for the Persuade domain of the Observational Rating Scale of Gatekeeper Skills. However, the researchers resolved rater discrepancies effectively through consensus meetings. Although a fidelity checklist was used for the scripted practice sessions, it was used inconsistently across the three studies. An error in the administration of the gatekeeper self-efficacy measure in one study resulted in a large amount of missing data, although participants with and without those data points were shown to be similar in baseline variables. One study has a one-group pretest-posttest design, and a number of threats to internal validity are likely. Additionally, in the same study, because the posttest was administered immediately after the training, evidence of a lasting impact from the training is not robust. In two studies, analyses did not account for the nesting of participants in schools.
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Readiness for Dissemination
Materials Reviewed
The materials below were reviewed for Readiness for Dissemination. The implementation
point of contact can provide information regarding implementation of the intervention
and the availability of additional, updated, or new materials.
Outcome monitoring tools:
- Original 9 Pre-Post Survey Items
- Pre-Post Knowledge Test Items
- Pre-Training Professional Knowledge and Training Needs Survey
- Self-Efficacy Pre-Post Training Survey Items
- Self-Report Experience With Suicide Behaviors for Baseline
- Self-Report Follow-Up Experience With Suicide at One Month Post-Training
- Self-Report Follow-Up Experience With Suicide 6 Months Post-Training
- Supporting Psychometrics and Research
Program Web site, http://www.qprinstitute.com
QPR Institute. (1995). Ask a question save a life [CD]. Spokane, WA: Author.
QPR Institute. (2002). QPR gatekeeper training for suicide prevention [DVD]. Spokane, WA: Author.
QPR Institute. (2010). QPR suicide prevention and risk reduction [DVD]. Spokane, WA: Author.
QPR Institute. (n.d.). QPR for communities: A suicide risk reduction program. Spokane, WA: Author.
QPR Institute. (n.d.). QPR for suicide prevention: Saving lives through excellence in education [Brochure]. Spokane, WA: Author.
Quinnett, P. (1992). Suicide: The forever decision. New York, NY: Crossroad Publishing.
Quinnett, P. (1993). The tender leaves of hope: Helping someone survive a suicide crisis. Sandpoint, ID: Selkirk Press.
Quinnett, P. (1995). Question, persuade, refer: Ask a question save a life [Booklet]. Spokane, WA: QPR Institute.
Quinnett, P. (2007). Certified QPR gatekeeper instructor's manual (2nd ed.). Spokane, WA: QPR Institute.
Quinnett, P. (2009). Counseling suicidal people: A therapy of hope (3rd ed.). Spokane, WA: QPR Institute.
Quinnett, P. (2009). QPR certified gatekeeper instructor self-study course (2nd ed.). Spokane, WA: QPR Institute.
Sowers, L., Quinnett, P., & Bratcher, K. (2003). Helping a child survive a suicide crisis: Keeping in touch [Brochure]. Spokane, WA: QPR Institute.
Training Web site, http://www.qprtraining.com
Watson, V. M. (n.d.). Options for QPR gatekeeper introductions.
Other dissemination materials:
- Introducing QPR to Schools: A Protocol
- QPR Certification Training Evaluation
- QPR Certified Gatekeeper Instructor's Recertification Letter
- QPR Gatekeeper Instructor Survey
- QPR Gatekeeper Quiz
- QPR Institute Suicide Risk Reduction Order Form
- QPR Instructor Newsletter (Q Blast--Winter 2011)
- The Certified QPR Gatekeeper Instructor's Self-Study Course Survey
Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)
External reviewers independently evaluate the intervention's Readiness for Dissemination
using three criteria:
- Availability of implementation materials
- Availability of training and support resources
- Availability of quality assurance procedures
For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.
Implementation
Materials
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Training and Support
Resources
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Quality Assurance
Procedures
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Overall
Rating
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3.3
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3.8
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3.3
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3.4
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Dissemination Strengths The program Web site provides general implementation information, including a list of available local instructors. A free downloadable copy of the book Suicide: The Forever Decision is available on the program Web site. The QPR gatekeeper training is easily accessible and targets a wide variety of audiences; it can be delivered as an on-site training by a certified instructor or online through the training Web site. The Ask a Question Save a Life booklet reinforces the key points covered during the QPR gatekeeper training and can serve as a future reference for participants. The option to become a certified instructor is available, either through in-person training or a home-study course. The QPR gatekeeper training includes a pre- and postassessment with a set passing grade for training participants. Follow-up assessments are available to monitor outcomes over time.
Dissemination Weaknesses Key implementation information is sometimes difficult to locate within larger documents, and the overall dissemination package is not organized to facilitate ease of use. The program Web site lacks a clear outline of the training options and support information to help implementers decide whether the program is a good fit for their needs. There is no guidance on how to use the resulting data from the assessments for program improvement.
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Costs
The cost information below was provided by the developer. Although this cost information
may have been updated by the developer since the time of review, it may not reflect
the current costs or availability of items (including newly developed or discontinued
items). The implementation point of contact can provide current information and
discuss implementation requirements.
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Item Description
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Cost
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Required by Developer
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1- to 2-hour, on-site QPR Gatekeeper Training for Suicide Prevention (conducted by a certified instructor)
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Varies by instructor
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Yes, one QPR gatekeeper training option is required
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1-hour, online QPR Gatekeeper Training for Suicide Prevention
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$29.95 per person
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Yes, one QPR gatekeeper training option is required
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8-hour, on-site QPR Gatekeeper Instructor Certification Course (includes 3-year certification; Instructor's Manual; teaching DVD; audio CD of QPR Gatekeeper Training; Counseling Suicidal People; Suicide: The Forever Decision; 25 Ask a Question Save a Life booklets; phone and email technical assistance and consultation from the QPR Institute; and quality assurance materials)
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$495 per person (minimum of 10 participants), plus travel expenses
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No
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QPR Gatekeeper Instructor Certification Self-Study Course (includes all items from the on-site course, Self-Study Course Manual, exam, and additional DVD with lectures)
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$495 per person
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No
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8- to 10-hour, online QPR Gatekeeper Instructor Certification Course for English-speaking participants outside of the United States or Canada (includes 3-year certification; Instructor's Manual; teaching DVD; audio CD of QPR Gatekeeper Training; electronic files of Counseling Suicidal People and Suicide: The Forever Decision; license to translate and print Ask a Question Save a Life booklets; phone and email technical assistance and consultation from the QPR Institute; and quality assurance materials)
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$495 per person
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No
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3-year instructor recertification
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$85
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No
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Ask a Question Save a Life booklet
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- $2.50 each for 1-25 copies
- $2 each for 26-500 copies
- $1.75 each for more than 500 copies
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Yes
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The Tender Leaves of Hope booklet
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- $2.50 each for 1-25 copies
- $2 each for 26-500 copies
- $1.75 each for more than 500 copies
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No
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Helping a Child Survive a Suicide Crisis brochure
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$40 for 100 copies
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No
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Additional Information Adults who want to become a certified instructor must choose one option for the delivery of the QPR Gatekeeper Instructor Certification Course. Volume and/or group discounts are available for the online QPR Gatekeeper Training for Suicide Prevention, the on-site QPR Gatekeeper Instructor Certification Course, and the QPR Gatekeeper Instructor Certification Self-Study Course. Discounts by country, on the basis of World Bank rankings, are available for the online QPR Gatekeeper Instructor Certification Course for English-speaking participants outside of the United States or Canada. Cost quotes are available upon request.
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Replications
Selected citations are presented below. An asterisk indicates that the document
was reviewed for Quality of Research.
Chen, P. Y., Moore, J. T., & Gibbs, J. (2009). Project Safety Net, CSU final report. Fort Collins, CO: Author.
Goldston, D. B., Walrath, C. M., McKeon, R., Puddy, R. W., Lubell, K. M., Potter, L. B., et al. (2010). The Garrett Lee Smith Memorial Suicide Prevention Program. Suicide and Life-Threatening Behavior, 40(3), 245-256.
Isaac, M., Elias, B., Katz, L. Y., Belik, S.-L., Deane, F. P., Enns, M. W., et al. (2009). Gatekeeper training as a preventative intervention for suicide: A systematic review. Canadian Journal of Psychiatry, 54(4), 260-268.
Keller, D. P., Schut, L. J. A., Puddy, R. W., Williams, L., Stephens, R. L., McKeon, R., et al. (2009). Tennessee Lives Count: Statewide gatekeeper training for youth suicide prevention. Professional Psychology: Research and Practice, 40(2), 126-133.
Molock, S. D., Matlin, S., Barksdale, C., Puri, R., & Lyles, J. (2008). Developing suicide prevention programs for African American youth in African American churches. Suicide and Life-Threatening Behavior, 38(3), 323-333.
Muehlenkamp, J. J., Marrone, S., Brown, D. L., & Gray, J. S. (2009). A college suicide prevention model for American Indian students. Professional Psychology: Research and Practice, 40(2), 134-140.
Quinnett, P., & Baker, A. (2009). Web-based suicide prevention education: Innovations in research, training, and practice. In L. Sher & A. Vilens (Eds.), Internet and suicide (pp. 41-61). Hauppauge, NY: Nova Science.
Reis, C., & Cornell, D. (2008). An evaluation of suicide gatekeeper training for school counselors and teachers. Professional School Counseling, 11(6), 386-394.
Tompkins, T. L., Witt, J., & Abraibesh, N. (2010). Does a gatekeeper suicide prevention program work in a school setting? Evaluating training outcome and moderators of effectiveness. Suicide and Life-Threatening Behavior, 40(5), 506-515.
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