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Intervention Summary

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Lifelines Curriculum

Lifelines is a comprehensive, schoolwide suicide prevention program for middle and high school students. The goal of Lifelines is to promote a caring, competent school community in which help seeking is encouraged and modeled and suicidal behavior is recognized as an issue that cannot be kept secret. Lifelines seeks to increase the likelihood that school staff and students will know how to identify at-risk youth when they encounter them, provide an appropriate initial response, and obtain help, as well as be inclined to take such action.

Lifelines includes a set of components to be implemented sequentially: a review of resources and establishment of administrative guidelines and procedures for responding to a student at risk; training for school faculty and staff to enhance suicide awareness and an understanding of the role they can play in identifying and responding to a student with suicidal behavior; a workshop and informational materials for parents; and implementation of a curriculum for students, the Lifelines Curriculum, to inform students about suicidal behavior and discuss their role in suicide prevention.

The research reviewed for this summary assessed only the Lifelines Curriculum, the last component to be implemented in the larger Lifelines program. It consists of four 45-minute or two 90-minute lessons that incorporate elements of the social development model and employ interactive teaching techniques, including role-play. Health teachers and/or guidance counselors teach the lessons within the regular school health curriculum. The Lifelines Curriculum was developed specifically for students in grades 8-10 but can be used with students through 12th grade.

Descriptive Information

Areas of Interest Mental health promotion
Outcomes Review Date: June 2009
1: Knowledge about suicide
2: Attitudes about suicide and suicide intervention
3: Attitudes about seeking adult help
4: Attitudes about keeping a friend's suicide thoughts a secret
Outcome Categories Suicide
Ages 13-17 (Adolescent)
Genders Male
Female
Races/Ethnicities White
Race/ethnicity unspecified
Settings School
Geographic Locations Urban
Rural and/or frontier
Implementation History Lifelines has been most widely used in Maine but is now being implemented in other States. Early versions of Lifelines were implemented in New Jersey in 1982, with the first evaluated version being implemented in 1990. A subsequent evaluation was conducted in Maine from 2003 to 2006. Since 2000, the Maine Youth Suicide Prevention Program (MYSPP) has been providing Lifelines teacher training in the State, where as of 2009, an estimated 33 schools were implementing the curriculum. Twenty-nine schools in Maine have been funded by Federal grants to implement and evaluate the comprehensive program.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: No
Evaluated in comparative effectiveness research studies: No
Adaptations No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories Universal

Quality of Research
Review Date: June 2009

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 1

Kalafat, J., Madden, M., Haley, D., & O'Halloran, S. (2007). Evaluation of Lifelines classes: A component of the school-community based Maine Youth Suicide Prevention Project. Report for NREPP. Unpublished manuscript.

Supplementary Materials

Kalafat, J., Elias, M., & Gara, M. (1993). The relationship of bystander intervention variables to adolescents' responses to suicidal peers. The Journal of Primary Prevention, 13(4), 231-244.

Kalafat, J., & Gagliano, C. (1996). The use of simulations to assess the impact of an adolescent suicide response curriculum. Suicide and Life-Threatening Behavior, 26(4), 359-364.  Pub Med icon

Lindsey, C. R., & Kalafat, J. (1998). Adolescents' views of preferred helper characteristics and barriers to seeking help from school-based adults. Journal of Educational and Psychological Consultation, 9(3), 171-193.

Outcomes

Outcome 1: Knowledge about suicide
Description of Measures Knowledge about suicide, including facts and myths about suicide and persons at risk for suicide, was measured using 8 true/false items from the Lifelines Student Questionnaire. Sample items on this self-administered questionnaire include "People who talk about suicide do not commit suicide," "Most teens who try to kill themselves really want to die," and "Suicide attempts are rare among good students."
Key Findings The intervention group demonstrated a significantly greater increase in knowledge about suicide from pretest to 2 weeks postintervention than the control group, which received physical education classes during the study and participated in Lifelines after the study (p < .001).
Studies Measuring Outcome Study 1
Study Designs Quasi-experimental
Quality of Research Rating 2.9 (0.0-4.0 scale)
Outcome 2: Attitudes about suicide and suicide intervention
Description of Measures Attitudes about suicide and suicide intervention were measured using 6 questions from the Lifelines Student Questionnaire. Sample items on this self-administered questionnaire include "Teens can't do very much to prevent teen suicide," "If somebody wants to kill themselves, nobody has the right to stop them," and "If a friend began to lose interest in activities and friends and sometimes said things like s(he) wasn't much good to anyone, would you mind your own business and let him/her have his/her privacy?" All items use a 4-point Likert scale from "strongly agree" to "strongly disagree" or "definitely would" to "definitely would not." Favorable attitudes reflect the belief that suicide is not inevitable, the belief that it is appropriate to intervene with a person at risk, and a willingness to intervene.
Key Findings The intervention group demonstrated significantly greater improvement in attitudes about suicide and suicide intervention from pretest to 2 weeks postintervention than the control group, which received physical education classes during the study and participated in Lifelines after the study (p < .001).
Studies Measuring Outcome Study 1
Study Designs Quasi-experimental
Quality of Research Rating 2.9 (0.0-4.0 scale)
Outcome 3: Attitudes about seeking adult help
Description of Measures Attitudes about seeking adult help were measured using 6 questions from the Lifelines Student Questionnaire. Sample items on this self-administered questionnaire include "It is important to have at least one adult that you can talk to if something is bothering you," "My school is prepared to help a student who might be thinking about killing him/herself," and "If a friend told you that s(he) was thinking about killing him/herself, would you talk to an adult about him/her?" All items use a 4-point Likert scale from "strongly agree" to "strongly disagree" or "definitely would" to "definitely would not." Favorable attitudes reflect the belief that it is important to seek adult help, the belief that there is an adult in whom the respondent could confide, the belief that the school is prepared to respond to a student at risk, and a willingness to seek adult help when someone (either self or a friend) is distressed or demonstrating signs of suicidal risk.
Key Findings The intervention group demonstrated significantly greater improvement in attitudes about seeking adult help from pretest to 2 weeks postintervention than the control group, which received physical education classes during the study and participated in Lifelines after the study (p < .001).
Studies Measuring Outcome Study 1
Study Designs Quasi-experimental
Quality of Research Rating 2.9 (0.0-4.0 scale)
Outcome 4: Attitudes about keeping a friend's suicide thoughts a secret
Description of Measures Attitudes about keeping a friend's suicide thoughts a secret were measured using 6 items on the Lifelines Student Questionnaire. Sample items from this self-administered questionnaire include "A friend's confidence about suicidal feelings should never be broken," "I would try to help a suicidal friend without getting help from someone else," and "If a friend told you s(he) was thinking about killing him/herself, would you respect his/her privacy and keep it a secret?" All items use a 4-point Likert scale from "strongly agree" to "strongly disagree," "definitely would" to "definitely would not," or "definitely tell someone" to "definitely not tell someone." Favorable attitudes reflect the belief that it is appropriate to break a friend's confidence if the friend is at risk of suicide and a willingness to share a friend's secret with someone who could help.
Key Findings The intervention group demonstrated significantly greater improvement in attitudes about keeping a friend's suicide thoughts a secret from pretest to 2 weeks postintervention than the control group, which received physical education classes during the study and participated in Lifelines after the study (p < .001).
Studies Measuring Outcome Study 1
Study Designs Quasi-experimental
Quality of Research Rating 2.9 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 13-17 (Adolescent) 51% Female
49% Male
95% White
5% Race/ethnicity unspecified

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:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Knowledge about suicide 2.0 2.8 3.0 2.5 3.0 4.0 2.9
2: Attitudes about suicide and suicide intervention 2.0 2.8 3.0 2.5 3.0 4.0 2.9
3: Attitudes about seeking adult help 2.0 2.8 3.0 2.5 3.0 4.0 2.9
4: Attitudes about keeping a friend's suicide thoughts a secret 2.0 2.8 3.0 2.5 3.0 4.0 2.9

Study Strengths

The measures used in the study have good validity. The quantitative ratings used to monitor intervention integrity showed acceptable fidelity. Analyses were well matched to the design, and sample size and power were adequate.

Study Weaknesses

Only one type of information on reliability was presented (i.e., Cronbach's alpha). The documents reviewed did not provide adequate information describing how missing data and attrition were addressed in the study.

Readiness for Dissemination
Review Date: June 2009

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.

Hazelden. (2009). Lifelines: A suicide prevention program. Frequently asked questions. Center City, MN: Author.

Kalafat, J., O'Halloran, S., & Underwood, M. (2007). Lifelines: A school-based response to youth suicide. Augusta, ME: Maine Youth Suicide Prevention Program.

Madden, M., Haley, D., Hart, S., Kalafat, J., & Saliwanchick-Brown, C. (2007). Summary: An evaluation of Maine's comprehensive school-based youth suicide prevention program. Retrieved online at http://www.state.me.us/suicide/docs/Final_CDCEvalPublicReport3-09.pdf

Maine Youth Suicide Prevention Program. (2002). A life saved: The story of a suicide intervention [DVD]. Augusta, ME: Author.

Maine Youth Suicide Prevention Program. (2006). Youth suicide prevention, intervention and postvention guidelines: A resource for school personnel (3rd ed.). Retrieved online at http://www.state.me.us/suicide/docs/guidelines.pdf

Maine Youth Suicide Prevention Program. (2008). Maine Lifelines intervention logic model. Augusta, ME: Author.

Maine Youth Suicide Prevention Program. (2008). MYSPP promotes the following components of school readiness to prevention suicide [PowerPoint slide].

Maine Youth Suicide Prevention Program. (n.d.). 2008-2009 Maine Youth Suicide Prevention Program training calendar.

Maine Youth Suicide Prevention Program: Lifelines Submission--Readiness for Dissemination Overview

Noodlehead Network. (2004). Suicide: A guide to prevention (2nd ed.) [VHS]. Burlington, VT: Author.

Program Web site, http://www.state.me.us/suicide

Quality assurance materials:

  • Lifelines/ASAP Classroom Observation Form
  • Maine Youth Suicide Prevention Program: Lifelines Student Lessons--Survey Administration Procedures
  • Maine Youth Suicide Prevention Program: School Readiness Rubrics

Underwood, M., Kalafat, J., & Maine Youth Suicide Prevention Program. (2009). Lifelines: A suicide prevention program. Center City, MN: Hazelden.

Wallet cards and stickers

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.8 3.5 3.8 3.7

Dissemination Strengths

Program materials provide guidance to multiple audiences involved in the implementation of the program, including school district administrators, teachers, parents, and students. The program curriculum is comprehensive and easy to understand, and materials are supplemented by detailed sample organizational policies to support the success of the intervention. Training and consultation are available from the developer at on- and off-site locations. A train-the-trainer component can be used to minimize extended training costs. Multiple tools are provided to support implementation fidelity. A student questionnaire for assessing participant change in knowledge and attitudes can be used to support quality assurance.

Dissemination Weaknesses

No mechanism is in place for school districts implementing the program to network with each other to continually develop and improve the model or to share problems encountered and lessons learned during implementation. Other than through consultation with the developer, implementers are not given any guidance on how to measure the impact of the program within a school or school district.

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.

Item Description Cost Required by Developer
Implementation package (for sites outside Maine) $225 Yes
Web Conference: "Is Your School Ready to Prevent Suicide?" Free No
Web-based training and consultation: Protocol Development Workshop $250 No
Online training: Making Educators Partners in Suicide Prevention Free No
1-day, on-site Lifelines implementation workshop, custom-designed for each school $2,200 per site per day, plus travel expenses No
Off-site Lifelines implementation workshop $200 per participant No
Consultation $125 per hour No
Quality assurance tools Included with implementation package No
Replications

No replications were identified by the developer.

Contact Information

To learn more about implementation, contact:
Kaylene McElfresh
(651) 213-4324
kmcelfresh@hazelden.org

Cheryl DiCara
(207) 287-5362
cheryl.m.dicara@maine.gov

To learn more about research, contact:
Mary Madden, Ph.D.
(207) 581-3494
mary.madden@umit.maine.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

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