Program Profile: Sources of Strength

This is a school-based, suicide prevention program designed to build socioecological-protective influences across a full student population, using youth opinion leaders from diverse social cliques to develop and deliver messaging aimed at changing the norms and behaviors of their peers. This program is rated Promising. Peer leaders in the intervention schools showed statistically significant improvements on perceptions and behaviors pertaining to suicide and on social connectedness.

A Promising rating implies that implementing the program may result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Goals/Target Population

The Sources of Strength program is a universal, school-based program that is designed to change the norms and behaviors surrounding suicide within a school community and increase social support and connectedness among students, including suicidal students. Sources of Strength aims to build socioecological-protective influences across the entire student population, to reduce the likelihood that vulnerable high school students will become suicidal. The program focuses on changing the norms and behaviors of students through youth opinion leaders. Youth opinion leaders are trained by certified trainers and supported (by adult advisors) in preparing and conducting suicide prevention-messaging activities. The activities are designed to change unhealthy norms around help seeking and trust towards adults, encouraging students to connect suicidal friends with a trusted adult (thereby reducing implicit acceptability of suicide in response to distress and increasing the acceptability of seeking help); improve communication between students and adults; and promote the use interpersonal and formal coping resources. 

Program Components

The Sources of Strength program is implemented in three phases: 1) school and community preparation, 2) peer-leader training, and 3) school-wide messaging. In the school and community preparation phase, each school uses a standardized procedure to nominate 5 percent to 10 percent of students as peer leaders, selecting key opinion leaders in diverse groups, including at-risk adolescents. In addition, each school selects multiple staff or community members to serve as adult advisors who will guide the peer leaders in safe suicide prevention messaging. Adult advisors receive 4 to 6 hours of training in the peer-leader curriculum and evaluation. School staff members may also receive a 1-hour orientation to the intervention, covering components of a suicide-prevention gatekeeper training and specific school protocol, which identifies and refers youths who exhibit suicidal ideation or concerning behavior. 

In the peer-leader training phase, peer leaders and adult advisors receive 4 to 5 hours of interactive training that follows 15 modules. The modules focus on eight protective ‘‘sources of strength’’ (family support, positive friends, mentors, healthy activities, generosity, spirituality, medical access, and mental health access), and on the skills for increasing those resources for themselves and other students. Another focus of the training is on engaging “trusted adults” to help distressed and suicidal peers. 

During the school-wide messaging phase, adult advisors support peer leaders in developing and implementing specific messaging steps. Adult advisors and peer leaders meet roughly every other week for 30 to 60 minutes to work on messaging strategies. During these meetings, adult advisors also help peer leaders practice applying and sharing the eight strengths in their own lives and their world. Peer leaders use multiple messaging activities (PSAs, presentations, videos, text messages, etc.) to encourage other students to develop and use their own sources of strength, including identifying and reaching out to trusted adults when they or their peers are in distress. Peer leaders engage in 12 to15 hours of these prevention activities throughout the school year.  

Key Personnel

School personnel play a significant role in the intervention. All staff members are asked to nominate peer leaders and also receive a 1-hour orientation to the intervention. Two to fifteen staff members (depending on the size of the team and interest of staff) are also selected and trained to serve as adult advisors to peer leaders, helping them develop and implement the school-wide messaging activities. These adult advisors are viewed as critical in the process of engaging and sustaining peer-leader involvement and should possess a corresponding set of skills. These skills include empathy, the ability to provide strength-focused feedback to peer leaders, group-facilitation skills, and the ability to model coping and sources of strength. Training is provided by certified Sources of Strength trainers.

Program Theory

The program is based on social-connectedness models of health and suicide prevention (CDC 2009) with a broader social-ecological framework (Bronfenbrenner 1979) that emphasizes the interplay among personal attributes, social contexts, and environmental conditions in influencing individual behavior. The implementation model draws on diffusion of innovations theory and research (Rogers 2003) showing the importance of trusted others in adopting new norms and practices. For adolescents, schools serve as appropriate program settings for suicide prevention programs, based on the expectation that they provide a cost-effective and significant peer social context and availability of supportive adults. Further, the intervention’s goals of increasing positive connections to adults and peers, increasing expectations of peer support for seeking help from trusted adults, and promoting use of positive coping behaviors are rooted in well-established ties between suicidal behaviors and social ties and norms (Insel and Gould 2008; Joe et al. 2007). 

Study

Wyman and colleagues (2010) used a cluster randomized-assignment research design to evaluate the Sources of Strength program in 18 schools in two phases. The first phase, conducted from 2007 to 2008, included 6 metropolitan schools in Cobb County, Georgia. The second phase, conducted from 2008 to 2009, included 12 predominantly rural schools (8 in New York and 4 in North Dakota). After blocking the schools by state and region and matching by size, 1 school from each pair was randomly assigned to the intervention group (to begin training immediately); the other school was assigned to the control group (on a wait list to begin training 5 months later). The metropolitan schools were larger and had more African American and Hispanic students than did the rural schools. No school withdrew or altered its assigned status. 

Peer leaders were recruited using identical, standardized procedures across all schools before assignment to intervention and control groups. Nomination forms submitted by staff members, administrators, and students identified a list of potential student leaders, which was further reviewed to select a diverse group of student leaders representing as many student friendship groups as possible. Each school in phase 1 recruited approximately 2 percent of all students, and each school in phase 2 recruited approximately 10 percent of all students. A total of 720 students were nominated (10 to 54 per school), of which 496 (68.9 percent) were enrolled with parents? permission and youths? assent. Of those students enrolled, 453 completed two assessments. The first assessment was conducted before any schools were randomly assigned to a condition (baseline).The second assessment was conducted 4 months later (approximately 3 months after messaging activities began at the intervention schools, but before peer-leader training started in the wait-list control schools). 

There were 268 peer leaders in intervention schools and 185 peer leaders in control schools. Peer leaders in the intervention and control schools were largely equivalent in gender and race/ethnicity; however, peer leaders in the intervention schools were 0.5 years younger than those in the control schools. Peer leaders in each intervention school completed at least three of the four messaging steps; participation in messaging ranged from 59 percent to 100 percent across schools. Thirty-six staff members (in four schools in phase 2) were interviewed after the messaging phase to check program fidelity. Approximately 97.2 percent reported observing or receiving intervention-specific messages, and 88.9 percent of those named as trusted adults reported that they had been contacted by a peer leader, as the intervention had intended.

The outcome measures of the study covered three constructs: 1) suicide perceptions and norms, 2) social connectedness, and 3) peer-leader behaviors. Suicide perceptions and norms were measured using the following scales: Help for Suicidal Peers, a 4-item scale assessing perceptions that adults help suicidal students in their school; Reject Codes of Silence, a 6-item scale assessing attitudes toward overcoming secrecy barriers to engage adults for suicidal peers; and Maladaptive Coping, a 4-item scale assessing perceptions such as suicide acceptability. Social connectedness was measured using the following scales: Help Seeking From Adults at School, 4-item scale assessing intentions to seek help, expectations about receiving help, and perceived peer norms about seeking help from adults at school; Sources of Strength Coping, a 9-item scale assessing the student?s status on eight resources that include family, friends, adult mentors, and services; and School Engagement, a 4-tem scale assessing attitudes and participation related to school. Peer leaders were also asked to list the names of adults to whom they would turn for help for a suicidal friend (Trusted Adults; only completed in phase 2 schools). Peer-leader behaviors were assessed using two questions that assessed the frequency of peer leaders? partnering with adults to help peers (Referred Distressed Peers to Adults; 2 items) and the frequency of supportive behaviors (Support to Peers; 2 items). There were no significant differences at baseline for any of the measures between peer mentors in the intervention and control groups. Peer leaders who completed posttest measures had higher baseline scores on School Engagement than those for whom posttest data were not able to be collected. Peer leader attrition, however, was not related to condition.

Intervention effects on peer leaders were tested using a 2-level, linear mixed-effects model, which included individual youths' gender, grade, age, race/ ethnicity, and baseline scores as random factors at level 1, and intervention condition and state location for the school as fixed factors at level 2. Schools were included in each model as random factors because randomization occurred at the school level. All analyses used an intent-to-treat approach by including all enrolled peer leaders regardless of their level of participation.

Because of the community or school-wide implementation of the program, community or school administration buy-in and support are essential (Sources of Strength, 2016). It is also important to identify and recruit adult advisors who are caring, connected, and positive adults in the school or community. Adult advisors participate in half-day training and also attend the half-day, peer-leader training. Adult advisors and peer leaders meet roughly every other week for 30 minutes to an hour to work on messaging strategies. Prior to implementing Sources of Strength, schools must also complete a review of their protocol and referral process for handling a distressed or suicidal student. This includes processes for identifying distressed students, addressing the mental health and social needs of those youths, and tracking their referrals.  

The implementation materials, including the program manual, Adult Advisor field guides, Peer Leader guides, campaign materials, and assessment tools are available from the developer. Additional program information is also available at the program website https://sourcesofstrength.org/.

Subgroup Analysis

Wyman and colleagues (2010) also found that the program had a significantly greater effect on peer leaders with lower (less favorable) baseline scores than on peer leaders with higher baseline scores on the following measures: Help for Suicidal Peers, Maladaptive Coping, School Engagement, Trusted Adults, and Referring Distressed Peers.

Additionally, Wyman and colleagues (2010) tested intervention impacts on representative samples of students in the 12 intervention schools in phase 2. Findings indicated positive and significant population-level intervention effects on students’ perceptions of adult help for suicidal peers (ES=0.63) and on students’ norms for seeking help from adults (ES=0.58). The intervention effects for the remaining two measures (rejecting codes of silence and Sources of Strength coping) were non-significant. Additionally, intervention effects on perceptions of adult help for suicidal peers varied by history of suicidal ideation; the intervention impact was greater for students with a history of suicidal ideation.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

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Mentoring for Youth Development

This practice provides youth with a positive and consistent adult or older youth relationship to promote healthy youth development and social functioning and to reduce risk factors. The practice is rated Effective in reducing delinquency and improving educational outcomes; Promising in improving psychological outcomes and cognitive functioning; and No Effects in reducing substance use.

Evidence Ratings for Outcomes

	Crime & Delinquency - Multiple crime/offense types
	Education - Multiple education outcomes
	Mental Health & Behavioral Health - Psychological functioning
	Mental Health & Behavioral Health - Cognitive functioning
	Mental Health & Behavioral Health - Social functioning
	Drugs & Substance Abuse - Multiple substances

Youth-Initiated Mentoring for Youth Development

Youth-initiated mentoring involves a hybrid approach in which youths are empowered to identify, develop, and strengthen natural mentoring relationships from their existing social networks, rather than being assigned a new mentor through a more formal mentoring relationship. The practice is rated Promising for improving psychological, health, school/academic, and social outcomes, and rated Ineffective for cognitive functioning outcomes.

Evidence Ratings for Outcomes

	Mental Health & Behavioral Health - Psychological functioning
	Education - Multiple education outcomes
	Mental Health & Behavioral Health - Social functioning
	Mental Health & Behavioral Health - Cognitive functioning

Why might a practice's outcome ratings differ from the ratings of specific programs encompassed by that practice?