The ‘Billboard Campaign’: Failed Attempt at Suicide Prevention by the American Foundation for Suicide Prevention – Angelica M. Garcia

Starting in 1987 the American Foundation for Suicide Prevention (AFSP), the leading national not-for-profit organization exclusively dedicated to understanding and preventing suicide, has been working on several activities to decrease the rate of suicide in the United States and some other countries. In 2007, AFSP initiated a campaign entitled Billboard Campaign, with a bright yellow and blue lettering as a means to call its attention (http://www.afsp.org/). The campaign focuses on educating Americans about the serious nature of depression, and urges those clinically depressed to see their doctor. The core message of the billboard is the presentation of a website - www.preventsuicidetoday.org - that contains a health questionnaire and other information about depression. The billboards are currently on display in the Minneapolis/St. Paul area and in Omaha, Nebraska, with planned expansion to additional cities in 2010. Unfortunately, no definite studies have been released. However, preliminary results note that 83 percent of those surveyed regarding this campaign felt that the billboards might encourage a depressed person to seek help. (1)

As the 11^th leading cause of death for all individuals and third leading cause of death for adolescents and young adults (ages 15-19 and 15-24) - only accidents and homicides occurred more frequently - and the second leading cause of death for college students, suicide is a major public health issue. (2) Suicide trends differ among young males and females. Males are much more likely to commit suicide than their female contemporaries, while female are more likely to attempt suicide than their male peers. The overall rate of suicide has been increasing from 10.5% in 1999 to 11.2% in 2006 with young adults ages 20-24 having the highest prevalence (12.4%) among 30 and under adults. (3)

Based on earlier mentioned preliminary results, the campaign appears to be potential effective; however, as a national campaign it will fail due to a number of reasons. The campaign was not tested on states where suicide rate are high, in addition to its narrow choice of material content. Secondly, the campaign’s goal may not have a broad reach due to its disregard for individuals’ safety. And finally, the socio-cultural variables that may significantly affect a person’s receptivity to and ability to act on the recommended behavior were also ignored when the goals of the campaign were developed.

The first means by which the Billboard Campaign seems to be limited is through its billboards’ placement and content. The AFSP do not state the reasons why they chose Nebraska and Minneapolis as target states for the pilot study of this campaign. However, while the promotional message may have reached the White, non-Hispanics population, other populations that are also at-risk might have not come into contact with the campaign causing an over-estimation of the actual potential of this campaign. Also, the overall rates of suicide in Nebraska and Minneapolis are amongst the lowest suicide rates in all states (10.8% and 9.9%, respectively). (3) Thus, this campaign may not have as good of an outcome in states like Montana and Nevada where the rates of suicide are the highest in the United States with 19.5% and 19.6%, respectively. (3)

Furthermore, these billboards were placed in major highways in Nebraska and Minneapolis. However, by displaying these billboards in highways only rather than in more local communities as well, the Billboard Campaign overlooks individuals from low socioeconomic status who are less likely to access major highways. Many local community individuals earning less than $20,000 per year do not have access to a car as a method of accessing major highways, while other individuals may rely on public transportation. For example, in states like Massachusetts, New York, and Washington DC, a great portion of the population, mostly low-income individuals, use public transportation (railroads, subways, and buses) as the primary mean of transportation without the need to access major highways. Thus, if the Billboard Campaign was to be implemented in one of these states it would fail to reach thousands of residents that do not commute out of a certain area, which includes a large number of at risk populations such as, college students and medical professionals.

In addition to being inaccessible to everyone who may need the services, young adults less than 15 years of age who do not have a driver’s license may not have regular exposure to these billboards. According to the US Census, 24.6% of the U.S. population is under 18. Since most of them do not drive, the percent of people who drive must be lower than 75%. Assuming 17% of people 18 years of age and younger drives, the percentage of people who drive a car in the U.S. would be approximately 61%. (4) Based on these estimations, only 39% of the population who drives will be exposed to the billboards. Studies done on billboard advertising show that because of the static location of billboards, their advertising has a high “impression rate”, in other words, it increases their effectiveness. (5) However, lack of this consistency by those who do not drive or do not access the highways regularly may affect its effectiveness.

The reach of the Billboard Campaign is further restricted because the primary means of acquiring information presented on the billboards is through the AFSP website. Although research has shown that “life expectancy and overall health have improved in recent years for a large number of Americans due to an increase focus on preventive medicine and dynamic new advances in medical technology”, there is still a large portion of Americans that do not benefit from this advances. (6) Racial disparities in health information access are quite substantial, particularly among the use of computers between Hispanics and Whites (42% and 56%, respectively) and between African-Americans and Whites. (7) However, internet use is related to more than race: it is highly partly associated with income level and education making the goal of the billboard more or less futile among low income individuals. (8) Even if minorities have access to the internet through programs such as, E-rate, which provide discount to schools and libraries for the cost of telecommunication services and equipment, reading health information online has been suggested that accessing health information using search engines and simple search terms is not efficient and has little effect on the frequency of physician visits. (9-10) Furthermore, scientific literature shows that mental health websites, specifically, are inconsistent and lack a complete evidence-based overview of the disorder. (11)

Moreover, the information offered in billboards, and the core message of the campaign is a self-performed questionnaire that serves as a screening tool for suicidal ideations. However, Ybarra et al. shows that self-reported behavior is different from actual behavior, which could lead to erroneous information regarding a person’s mental health problems. (11) In addition, the intervention is driven so that once the questionnaire if completed, it is taken to the person’s primary care physician for further evaluation. The cons of this specific questionnaire is that instructions for evaluation by the primary care physician are available to view by the person filling the questionnaire, which could cause individuals to self-analyze their answer and continue avoiding mental health services. Fearful responses to actual or imagined aspects of mental health service seeking and consumption may also serve to increase individuals' reluctance to seek help. (12) Also, it is questionable whether the provider can see the individual immediately and whether the provider is equipped to adequately assess, treat, or refer a suicidal individual. (13) This is particularly an issue among health resources in poor, rural, or other underserved areas. (13)

Lastly, the information available on the website does not target secondary parties who may need to seek services for a family or friend. Theorists and researchers in developmental psychopathology have expressed the importance for the role that extra-individual influences play in human development. (14) Yet, a person seeking help for a friend with suicidal ideations that comes across with this billboard will be left wondering how to help.

On top of the exclusionary dissemination of campaign information, the second way the Billboard Campaign message is constrained is by its disregard for individuals’ safety. Most of the current billboard campaigns (AT&T, PETA, Coors Light, Marlboro) have been effective due to their minimalistic amount of words but, considerably large images. (15-18) Yet, the billboard used by the Billboard Campaign impairs safety rather than enhance it. Instead of having a captivating image with a short message such as a “catchy” phone number (i.e. 1-800-273-TALK), AFSP’s campaign provides a long website that may be difficult to remember. (19) Viewers are exposed to billboards for an average of seven seconds. (20) Some drivers may attempt to write down the message in order to avoid forgetting it. Writing is one of many distractions (eating, drinking, reaching for an object, etc.) that is frequently associated with decrease driving performance, as measure by higher levels of no hands on steering wheel, and contributes to traffic crashes. (21) The National Highway Traffic Safety Administration (NHTSA) has estimated that driver inattention is a contributing factor in 25–30% of crashes. (22)

Last but not least, the campaign’s presentation discount potential socio-cultural context. The Billboard Campaign message is not adaptable or accessible to diverse populations. For example, the campaign does not address potential language barriers. In the U.S., 19.7% of the population speaks a language other than English at home and only 55.9% can speak English very well. (23)

Additionally, foreign-born populations are reported to be less likely to have a high school diploma, more likely to be poor, least likely to have health insurance or to have a usual source of health care, more likely to be obese the longer they live in the U.S.; all of which are recognized as risk factors for mental health symptoms. (24) Therefore, billboards that fail to address this groups will not be successful at reaching a diverse population of at-risk individuals.

The Billboard Campaign also fails at addressing racial disparities in the health care delivery. By attempting to ask subjects to fill a questionnaire and ask to be given to their primary care physician, this campaign is under the assumption that everyone seeking their services has access to health care services. This campaign disregards the fact that about 30 percent of Hispanics and 20 percent of African-Americans lack a usual source of health care compared with less than 16 percent of whites. (25)

Ethic/racial minorities report lower health care satisfaction and greater discrimination, low health care affordability, geographic access, transportation to and from services, and fewer preventative procedures. (26) Moreover, studies have shown that racial/ethnic minorities are more likely to be exposed to violence, which is associated with mental health problems, such as depression, suicidal ideation, and post-traumatic stress disorder. (27) By using race as an individual level, categorical variable, the AFSP has overlooked the complexities of health disparities that arise when cultural factors are considered.

In addition, the patterns of trust and resulting decrease participation in the health care system vary considerably by race and culture. The Billboard Campaign completely disregards this important point. A history of racial discrimination in medical research and the health care system has been linked to a low level of trust in health care services among African-Americans. (28) Many reported physician’s misunderstanding of symptoms and illness that influence their interactions with the physician. (29) Overall, racial and ethnic minority group members report less positive perceptions of physicians. (29) More specifically, social attitudes and perceptions toward the pursuit of mental health care have been shown to differ among different racial/ethnic groups. (30) Although African-Americans display more positive attitudes towards seeking mental health care than did Whites, they used fewer services. (30) Many foreign-born immigrants seek help within their community rather than seeking professional help. Neighborhoods, ethnic communities, and non-coresident kin play an important role in the lives of immigrants. (31) Misgivings and suspicions toward organized medicine must be addressed before at-risk individuals can be expected to come forward about their mental health issues to their physicians, per the Billboard Campaign’s recommendations.

Finally, the Billboard Campaign’s primarily supposition is that health behaviors are rational, such that awareness of suicide ideations will inspire action, in this case, awareness of a problem and instant seeking of help. These assumptions appears to be derived from the Health Belief Model (HBM), with the Billboard Campaign disregard for possible social influences (i.e. racial/ethnic difference, socio-cultural and economic status) that are related to mental health problems including, suicide ideations; thus, making this campaign unsuccessful at decreasing suicide rates. The Billboard Campaign appears to have been laid out based on the HBM since is goal is to make people aware of their problem and seek help. According to the HBM, internalizing this susceptibility and potential severity should cause individuals to see the benefit in a behavior (in this case accessing the website and filling out the questionnaire) and therefore cause them to intend to adopt the behavior. (32) Nevertheless this model assumes that there are few or no impediments to adopting the new behavior. It also does not take into account the differences in attitudes and beliefs among different racial/ethnic groups. Because these factors, specially, the existence and impact of stigmas as well as different attitudes towards mental health services, are excluded from the Billboard Campaign’s design, its reach is significantly limited.

The SOS Program and the ER Intervention

SOS Program (33)

The SOS Program is a prevention program that focuses on reducing the incidence of suicide among adolescents. This program incorporates four suicide prevention strategies;

1. Curricula with the goal of raising awareness of suicide
2. Brief screening for depression and risk factors that could lead to suicidal behaviors
3. Creation of an SOS website
4. Radio and television public service announcements, with materials made available through the SOS website

The premise behind the SOS program is what is known as ACT,

·Acknowledge the signs of suicide

·Show the person that you Care and want to help

·Tell an adult about the problem.

Social Learning Theory (SLT) is based on the tenet that people do not learn behaviors isolated from external interactions. (34) The theory stresses that a large contribution to adopting behaviors stems from observing and then emulating the actions of others within an individual’s community. Awareness of an individual’s activities and consequences facilitates the enforcement and development of previously nonexistent behaviors to the observant individual. Three principles encapsulate the theory’s essence: a) Observational learning is best acquired by translating the behavior to symbols before performing the behavior in an exaggerated manner; b) The modeled behavior is more easily learned if its consequences are valued by the observing individual; c) If the behavior is highly valued or admired and it serves a purpose for the individual, he/she will be more apt to follow the modeled action. The adolescent population seems ideal for employing SLT techniques to reduce suicide ideations.

More than just preventing suicide, the SOS program develops social involvement and emotional investment via group activities as derived from the SLT. The program will be easily implemented on schools by health educators and at the time, will be less costly than other suicide prevention programs that include mental health screening. As a result, this program will show a positive short-term impact on suicide behavior and knowledge of and attitude towards depression and suicide in a diverse student population.

Additionally, high schools in the U.S. have a diverse population of students. More than a third of Hispanics and African Americans population are enrolled in high school (85.6% and 82.9%, respectively). Based on the experiences of program implementation in Hartford and Columbus, where there is a diverse population among high school students, this program would also have positive outcomes if implemented in the city of Boston. (35)

To address language barriers, this intervention will supply questionnaires in both, English and Spanish to capture students in English as a Second Language (ESL) status who may also need the services. In order to account for the lack of trust among racial/ethnic minority groups, culturally-competent trained nurses will be in charge of administering the questionnaire and assessing for risk factors.

The SOS website will mimic that of the Alive campaign, whose website promote awareness for suicide prevention and depression through progressive ideas and actions; the inclusion of charities, education of the public, and a combination of both, national and international resources. (36)As part of the resources available to the public, radio and television public service announcements will be distributed in places such as shopping centers, grocery stores, local community centers, and primary care offices.

ER intervention (37)

In contrast to the SOS program, the ER intervention is for those individuals who have attempted suicide and may be at risk for further suicide attempts. The ER intervention is an 18-month intervention that addresses barriers to follow-up outpatient treatment. This specialized intervention, when compared with the standard care at the ER, is found to reduce suicide reattempts and increase adherence to an outpatient therapy via,

·Family outpatient therapy program

·Video presentation about suicide and the benefits of the intervention

One important aspect of this specialized ER intervention is that it includes the parents of the suicide attempter (SA); in particular, it tackles maternal emotional distress and family cohesion among SAs who have many symptoms of suicide. This is a crucial aspect of the intervention since it takes into consideration the immigrant population, who is more likely to rely on family support. Like the SOS program, cost for delivery of this intervention will be relatively low. Moreover, anyone can obtain this service, regardless of income since it is administered in the ER.

In addition, the length of this intervention (18 months) can benefit individuals by having a constant interaction with medical professionals that can provide support, and care, and development of trust.

Conclusion

In an effort to meet the needs of those individuals with suicidal ideations, specially, high school students, and help reduce the percentage of suicide attempts, I strongly recommend implementation of the SOS program and ER intervention as a substitution of the Billboard Campaign. I believe that the SOS program will be an essential component to all high schools that aim to benefit adolescents from diverse cultural backgrounds. It not only addresses the issue of providing organized, comprehensive education about suicide, but it also applies screening components that would help students identify depressive symptoms and talk to a responsible adult before attempting to commit suicide regardless of race/ethnic background or income. By serving the diverse population of high school students, the SOS program will achieve the overall goal of reducing suicide rates. On the other hand, the ER intervention will work on reducing suicide reattempts among all age groups, regardless of gender or ethnicity. The ER intervention will help build the type of trust and physician-patient relationship that could lead to successful health outcomes; in this case, a reduction in suicide rates and reattemps.

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33. Garcia A. SOS Program (a faux designed intervention by me)

34. Garcia A. ER Intervention (a faux designed intervention by me)

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