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Abstract
This article presents preliminary evidence that media campaigns are valuable in promoting suicide prevention hotlines to Veteran households by reporting data from 2526 telephone surveys. Findings from this study underscore the need for further investigation of the use of media campaigns to support suicide prevention initiatives aimed at Veteran populations.
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Introduction
Mass media campaigns are a powerful tool for promoting positive health behaviours, and those well executed can be successful in transmitting information to raise awareness and produce attitude and behaviour change for various health risks across large populations.1 ,2 The implementation of such campaigns is identified as an objective in the 2012 National Strategy for Suicide Prevention,3 yet few investigations have explored the potential of these communicative interventions, particularly with segments of the population at high risk. US Veterans are one such group with multiple risk factors for suicide including their ‘high prevalence of depressive disorders and comorbid psychiatric conditions’ (p. 2193).4 Media campaigns may provide a viable method to broadcast valuable messages to this group that can help to reduce related risk and encourage appropriate help seeking behaviours. To date, however, little is known of the efficacy of suicide prevention messaging with Veterans.5 Accordingly, this study examines the potential for mass media health campaigns to promote suicide prevention hotlines to this community.
Although the extant literature on communication efforts addressing suicide is sparse, what research does exist reveals some promise in using public messaging to raise awareness and promote help seeking (eg, calls to telephone help lines) among the general population,6 ,7 but also underscore the challenges in trying to impact attitudes and behaviours that are resistant to change (eg, message competition with pervasive product marketing; oppositional social norms).8 ,9 These findings demonstrate that further investigation of suicide prevention media campaigns is needed.
Our experiences with media do not occur in a ‘vacuum free from interpersonal networks’ (p. 420),10 and a better understanding of campaign effects requires consideration of the targeted audience and those closest to them, such as family. Patterns of health behaviour, including information seeking and the utilisation of services, are often stable, similar and interrelated among family,11 and members may play an integral role in connecting Veterans in a crisis to help. As such, participants in this study include Veteran households.
This article explores the associations between media campaign exposure and the likelihood of hotline use, if in need. Additionally, in the absence of direct personal experience with calling a hotline, participants may look to other people's behaviour when evaluating their own intentions to seek help.12 Therefore, this article will also examine the role an interpersonal connection to a resource (knowing someone who has used a suicide prevention hotline) may play in the likelihood of use.
Methods
Sample and data collection
As part of a larger study evaluating suicide prevention efforts aimed at Veteran populations, telephone interviews were conducted from May 2009 to March 2010 with residents 18 years and older living in one of 12 metropolitan areas across the USA where data collection occurred (see figure 1 for study sites). Telephone numbers were randomly selected from local telephone books, and one attempt was made to contact potential participants from each household. No repeat calls were made, and those contacted who were younger than 18 years of age, unable to provide verbal consent or did not speak English were excluded from participation. One adult per household was recruited. A priori power analyses determined an optimal sample size of approximately 500 participants per site. Participation rates ranged from 14.1% to 34.3% (see figure 1 for a complete listing).
Overall participation rates by city.
Measurement
Participants were asked to report their recent exposure (past 30 days) to public service/campaign messaging (ie, billboards, print, radio or television ads promoting hotlines), if they had known anyone to use a hotline (interpersonal connection) and the likelihood they themselves would call a hotline if in need. In an effort to reduce bias, participants were asked to respond to these questions for several different public health concerns (suicide prevention, HIV/AIDS, drug abuse, smoking cessation, child abuse/neglect and domestic violence). Responses were scored Yes (1) or No (0) except for likelihood of one's own use in which ‘not at all likely, somewhat likely, and likely’ responses were coded as Low, and ‘very and extremely likely’ responses were coded as High. Limited demographic information was collected including age, gender, if participant was living in a Veteran household, and if so, had they received any service from the Veterans Health Administration. This study was determined to be exempt by the Syracuse VAMC Institutional Review Board.
Data analysis
The analyses reported in this paper are restricted to individuals in Veteran households. Data from completed interviews were weighted by age and gender, and descriptive statistics were tabulated by frequency and SD. Logistic regression was used to identify associations of demographic variables, message exposure and interpersonal connection with self-reported high likelihood of hotline use if in need. All statistical analyses were performed using SAS 9.2. Missing data were replaced using a maximum likelihood method of imputation (Proc MI). The percentage of data imputed was less than 5% for each question (see online supplementary appendix A for complete listing).
Results
A total of 2526 Veteran households completed interviews for this assessment. 58% (n=1475) of respondents were men, and 42% (n=1051) were women. Participants’ ages ranged from 18 to 95 (M=66, SD=14.43) with 59% aged 65 and older (see figure 2). 31% reported that a household member had used Veterans Health Administration services.
Percent of participants in each age group (2526 participants).
33% of respondents reported seeing suicide prevention messaging in the past 30 days, and 13% knew someone who had previously used a suicide prevention hotline. 48% of participants reported that if in need they would be highly likely to use a suicide prevention hotline (vs low). The remaining results focus on associations with high intent (likelihood) to use a suicide prevention hotline.
Figure 3 summarises the results of the multivariate regression model accounting for age, gender, media exposure and interpersonal connection. Those respondents who had seen suicide prevention messaging within the past 30 days were more likely (OR 1.57; 95% CI 1.24, 1.99) to report high intent to use a hotline than those who were not exposed. Additionally, participants who knew someone who had used a suicide prevention hotline were also more likely (OR 1.79; 95% CI 1.23, 2.60) to report high intent than those with no interpersonal connectivity.
Associations with high likelihood to use a hotline (2526 participants).
Male participants were less likely (OR 0.52, 95% CI 0.42, 0.66) to report a high intent to use the hotline if in need than their female counterparts. This is consistent with existing research that identifies males as possessing less favourable attitudes and willingness to seek psychological help than women.13 ,14
An interaction term was considered in the model to assess the associations between message exposure and interpersonal connection with high intent to use a suicide prevention hotline, but was not found to be significant.
As a comparison, multivariate logistic regressions were repeated for each additional health context explored in the survey (HIV/AIDS, drug abuse, smoking cessation, child abuse/neglect, domestic violence). Results were similar to those found for suicide prevention (see figure 3) with the exception of smoking cessation where media exposure had no significant association with a high likelihood of hotline use.
Discussion
This research provides preliminary evidence that media campaigns are valuable in promoting suicide prevention hotlines to Veteran households. Specifically, recent message exposure was associated with ‘high intent’ to use one if there was a perceived need. This type of messaging may serve as an initial source of encouragement for those at risk to seek help, and hotlines may benefit from motivation generated from message exposure.15 However, this motivation may only be short term, and campaigns should consider the continuation of messaging activities so as to support and sustain help seeking behaviours. Additionally, identifying specific resources for help can facilitate the translation of information provided in these messages into action.12 For example, suicide prevention campaigns that advocate hotline use may increase individuals’ perceived self-efficacy by providing a tool to alter behaviour with.
Interpersonal connection was a powerful motivator to seek help, and the use of a suicide prevention hotline by ‘anyone’ in the participants’ social networks was associated with high intentions for them to use it as well. The relationship between these variables was stronger than direct exposure to media in this study, which may have important implications for the design of campaigns targeting this population. For example, efforts to promote health behaviour to this group could be improved by considering the way in which information is shared, and to integrate social networks into messaging activities as a complement to media campaigns. More specifically, campaigns should encourage individuals to seek help and share the information and resources provided in messages (ie, hotline information) with others (Veterans and those closest to them). This strategy could substantially widen the reach and potential effect of these media campaigns.16 Similar methods may be useful to promote different types of hotlines to Veteran households as results were evident across different health contexts measured in this study.
This approach may also have important indirect effects for suicide prevention. The diffusion of such information through interpersonal channels may spur changes in public discourse by loosening normative constraints on talking about suicide and use of preventive services. Future research should consider and explore the secondary diffusion of media campaign messages through this community.
No interaction effect was found in this study, which may indicate that health information can be effectively transmitted to Veteran households through distinct channels. This can make communicating with this group relatively easier, and may be especially important when disseminating urgent information. However, in order to maximise message exposure, the adoption of a multi-channel approach is essential.17 ,18
While this study contributes important insights that may inform current and future campaigns aimed at the Veteran community, limitations of this research should be acknowledged. First, although the sample was weighted, results may not generalise to the entire target population given the potential for subject selection bias (ie, participants were primarily over the age of 50). Additionally this article examined the responses of Veteran households, and although targeting suicide prevention messaging toward family and friends is important as they may be equipped to intervene,19 future research should tease out potential nuances between Veterans and their family members. All analyses were based on self-reports of exposure to campaign media and use of crisis services by others, which cannot be independently corroborated and is subject to participant bias (ie, inaccurate recall of message exposure or interpersonal connection to hotline, social desirability bias in responses). Finally, this study represents a single, cross-sectional snapshot of media's ability to promote hotlines to Veteran households. The next step in this research trajectory should measure effects for specific campaigns over time that are targeted towards Veterans and their households, including the evaluation of ongoing suicide prevention media campaigns launched by the Department of Veteran Affairs.
This article demonstrates the potential of campaigns to promote the use of suicide prevention hotlines to Veteran households. Mass media health campaigns that achieve even small to moderate effects can have a significant impact on public health1 ,2 and future research of their potential with Veteran populations is warranted.
What is already known on the subject
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US Veterans may be at an increased risk for suicide, and public health messaging may provide an avenue for disseminating messages to this group that encourage help seeking and promote the use of mental health services.
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Few investigations have explored the potential for communicative intervention addressing suicide prevention.
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Little is known of the efficacy of suicide prevention messaging with Veterans.
What this study adds
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This study represents one of the first empirical investigations (known to the authors) of the potential for mass media campaigns to support suicide prevention efforts targeted toward Veteran populations.
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This research provides preliminary evidence that media campaigns are valuable in promoting suicide prevention hotlines to Veteran households and considers ways to improve health promotion efforts aimed at this group.
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The next steps for developing and evaluating suicide prevention messaging targeted towards this group are discussed.
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Acknowledgments
This material is the result of work supported with resources and the use of facilities at the VISN 2 Center of Excellence for Suicide Prevention at the Canandaigua VA Medical Center. We thank all of the Center of Excellence survey Center staff who participated in the data collection process.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online appendix
Footnotes
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Contributors All authors meet the uniform requirements for manuscripts submitted to medical journals, and contributed to analysis and interpretation of findings, and the writing of the manuscript. All authors have seen and approved the final version of the paper.
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Competing interests None.
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Ethics approval Syracuse VAMC Institutional Review Board.
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Provenance and peer review Not commissioned; externally peer reviewed.