Improve Surveillance of Suicide and Evaluation of Prevention Programs

1A

Use Wisconsin data to describe the impact of suicidal thoughts, attempts, and deaths and expand data linkages to further the understanding of suicide.

 

Prevention is driven by data, so an accurate and comprehensive picture of the impact of suicide (including thoughts, plans, and attempts) is crucial for prevention planning in Wisconsin. At present, data are available on suicide deaths and self-harm emergency department visits and hospitalizations through the Wisconsin Interactive Statistics on Health (WISH) data query system. Information on suicidal thoughts, suicide risk, and suicidal behavior is available through a variety of sources, including the Youth Risk Behavior Survey (YRBS), the Wisconsin Behavioral Risk Factor Survey (BRFS), which is part of the Behavioral Risk Factor Surveillance System (BRFSS), and the County Health Rankings. These data systems alone provide a wealth of information on suicide, but with increased dataset linkage capabilities, a more thorough and complete representation of these issues can be captured.

One means of data collection involves the efforts of death review teams, which could be expanded with additional resources. For instance, it would be helpful if Suicide Death Review Teams (SDRTs) across the state could enter data into a unified database to allow for place-based analysis of risk and protective factors. Also, to enhance the data that is collected, the state could potentially develop guidance for SDRTs similar to those developed for Child Death Review Teams (CDRT).

The CDRT model provides credibility, guidance on running a team, standardization of data reporting, and assistance in informing prevention strategies. The CDRT model has been used in Winnebago County to assist in the formation of a local Opioid Fatality Review Team. This model can also be used by any county wanting to develop teams for suicide death review. In collaboration with partners, the state could potentially improve overall cohesiveness for this type of data collection and application to prevention work.

Another important step for data collection is to ensure that populations at high-risk and populations of smaller numbers are represented in data collection. The following is taken from the Suicide Prevention Resource Center’s (SPRC’s) State Suicide Prevention Infrastructure Recommendations:24

Well-established, large datasets may not always adequately include underserved communities. In these cases, it’s important to make efforts to ensure that underserved communities are better represented (e.g., by targeted recruitment, oversampling, or other methods). When data on underserved populations cannot be obtained reliably or in a large enough number through such channels, the state suicide prevention program should work to address these gaps through stakeholder conversations about other data options, including alternate existing sources and/or the creation of new ones. Partners who represent specific communities can help in a number of ways:

  • Locating existing data on their specific population(s).
  • Exploring gaps in traditional data sources.
  • Supporting data collection among their key audience via qualitative methods, such as focus groups and key informant interviews.
  • Providing data and insight themselves.

The SPRC recommendations also stress that states should actively consult with and include historically underserved groups, such as tribes and refugee populations, in conversations about appropriate ways to ensure that accurate data on suicidal behaviors is collected and used appropriately.

24. Suicide Prevention Resource Center. (2019). Recommendations for state suicide prevention infrastructure. Waltham, MA: Education Development Center, Inc.

4A: Use data to describe the impact and further the understanding of suicide

Opportunities for Action Resources
Encourage local coalitions and others to use data to inform prevention efforts. Wisconsin Interactive Statistics on Health (WISH)
https://www.dhs.wisconsin.gov/wish/index.htm
Wisconsin Behavioral Risk Factor Survey (BRFS)
https://www.dhs.wisconsin.gov/stats/brfs.htm
County Health Rankings
https://www.countyhealthrankings.org/
Data You Can Use
https://www.datayoucanuse.org/
Work with school districts to encourage participation in the YRBS and utilize survey results to inform local youth suicide prevention efforts. Wisconsin Department of Public Instruction (DPI)—Youth Risk
Behavior Survey
https://dpi.wi.gov/sspw/yrbs
DPI—Youth Risk Behavior Survey Special Topic: Suicide and
Help Seeking
https://dpi.wi.gov/sites/default/files/imce/sspw/pdf/yrbssuicidehelpseeking.pdf
Improve qualitative review and documentation of suicide risk among special populations in Wisconsin through interviews, focus groups, etc. ETR—Advancing Health Equity
https://www.etr.org/blog/qualitative-research-helping-to-move-health-equity-forward/
University of Wisconsin-Milwaukee, Zilber School of Public Health
https://uwm.edu/publichealth/
Develop and provide guidance to Suicide Death Review Teams similar to that for Child Death Review Teams. Child Death Review Teams
https://www.chawisconsin.org/initiatives/injury-prevention-death-review/child-death-review/

 

Opportunities for Action Stakeholders
Link information from Suicide Death Review Teams across the state into a unified database.
  • Suicide Death Review Teams
  • Medical College of Wisconsin
  • Wisconsin Department of Health Services
  • Wisconsin Department of Justice
  • Children’s Health Alliance of Wisconsin
Link data from multiple sources with the Wisconsin Violent Death Reporting System for a more comprehensive review of suicide deaths and self-harm injuries.
  • Wisconsin Department of Health Services’ outreach to other state agencies and stakeholders

 

 

4B

Work in collaboration with existing organizations to standardize and enhance capacity for investigating and reporting suicide deaths.

 

Currently, there is no standardization for the data collected in Wisconsin on suicide deaths. Suicides are investigated by coroners and medical examiners, some of whom have received specialized training in death scene investigation. However, there is no state level mandate for training for death scene investigators, which may lead to variability in the quality and quantity of data collected for suicide deaths. Having high quality data regarding suicide deaths is important, as this data will allow for the formulation of data-driven prevention strategies that are specific to our state and its residents.

 

Development of the suicide death investigation form in Winnebago County

The suicide prevention subcommittee of the Winnebago County Child Death Review Team identified the following:

  • There was no standardization for the collection of data on suicide deaths in Winnebago County. The data that was collected was varied and limited, which made it difficult to identify risk factors and develop prevention strategies that were specific for the community.
  • There is no standardization for the collection of suicide data at the state level in Wisconsin.
  • The Winnebago County Public Health Department took the lead and partnered with other community stakeholders to develop a suicide death investigation form.
  • The suicide death investigation form is designed to be completed by the coroner in partnership with law enforcement.

The suicide death investigation form has multiple uses:

  • Guide coroners and law enforcement, who have varied expertise, to collect standardized data in real time.
  • Identify risk factors and develop robust prevention strategies specific to our community.
  • Collect data on adverse childhood experiences (ACEs) to help identify the impact of ACEs in a suicide death.
  • Gather contact information for family, friends, and co-workers of the deceased, so that grief outreach and suicide prevention education (postvention) can be provided as appropriate.
  • Could be used as a resource for a suicide death review team, as there is currently no state level guidance on that.

Ongoing efforts include:

  • The coroner is filling out the new suicide death investigation form. We are in the process of educating law enforcement about the process of suicide death investigation.
  • The coroner works with Community for Hope, the local suicide prevention support agency, for outreach to survivors of suicide loss.
  • Resources are limited for developing a suicide death review team. It is expected that a small team led by a suicide prevention coordinator
  • will analyze the data, develop reports, and recommend specific suicide prevention strategies to the community.

 

4B: Standardize and enhance capacity for investigating and reporting suicide deaths

Opportunities for Action Stakeholders
Provide death investigation guides for coroners, medical examiners, and law enforcement to improve and standardize the data collected on suicide deaths.
  • Wisconsin Department of Health Services
  • Wisconsin Coroners and Medical Examiners Association
  • Wisconsin Department of Justice
Standardize death scene investigation across the state in order to improve the completeness of data collected. 
  • Wisconsin Department of Health Services
  • Wisconsin Coroners and Medical Examiners Association
  • Wisconsin Department of Justice
  • Local Suicide Prevention Coalitions
Work with local suicide prevention coalitions to provide guidance and enhance capacity on the formation of death review teams.
  • Suicide Death Review Teams
  • Medical College of Wisconsin
  • Wisconsin Department of Health Services
  • Wisconsin Department of Justice
  • Children’s Health Alliance of Wisconsin
Facilitate the administration of psychological autopsies to better determine the proximate causes for the suicide, better understand the pathways that led to the suicide, and uncover potential avenues for prevention.
  • Psychological Autopsy Investigators
  • Medical College of Wisconsin
Improve data captured during mental health or self-harm injury hospitalizations or emergency department visits.
  • Wisconsin Department of Health Services
  • Wisconsin Hospital Association
  • Electronic Health Record System Vendors

 

 

4C

Improve and expand evaluation of suicide prevention programs.

 

The Centers for Disease Control and Prevention has stressed the importance of tracking the progress of prevention efforts and evaluating the impact of those efforts. In Preventing Suicide: A Technical Package of Policies, Programs, and Practices, the
CDC notes:25

Evaluation data, produced through program implementation and monitoring, is essential to provide information on what does and does not work to reduce rates of suicide and its associated risk and protective factors. The evidence-base for suicide prevention has advanced greatly over the last few decades. However, additional research is needed to understand the impact of programs, policies, and practices on suicide (and suicide attempts, at a minimum), as opposed to merely examining their effectiveness on risk factors. More research is also needed to examine the effectiveness of primary prevention strategies (before risk occurs) and community-level strategies to prevent suicide at the population level.

In addition, researchers have looked at successful prevention programs and identified “9 Principles of Effective Prevention Programs.” One such principle is Outcome Evaluation, which states that “a systematic outcome evaluation is necessary to determine whether a program or strategy worked.”26 Evaluation of suicide prevention activities (gatekeeper training, in particular) must move beyond just considering the number of trainings provided and the number of participants reached, and look instead to evaluating changes in knowledge about suicide, shifting beliefs about prevention, reducing reluctance to intervene, and increasing self-efficacy to intervene. Program evaluation should also consider opportunities for longitudinal (3 month or 6 month) follow-up to determine the number of interventions that occurred as a result of the training.

Evaluation questions

While evaluation of efforts remains a gap in Wisconsin and nationally, evaluation is an essential piece of a comprehensive suicide prevention approach. Coalitions, local health departments, and other partners may choose to use the questions below to structure their plans to implement and evaluate a community suicide prevention initiative. When able, local groups should report any results of their evaluations to the state lead on suicide prevention to help inform future prevention efforts. The following evaluation questions are taken from the Washington State Suicide Prevention Plan.27

  1. What is the problem you want to address? Explain in one or two sentences what problem your community, institution or system needs to solve. For example: There is not a school counselor at my school; There is not a culturally relevant recognition and referral training available for my community; The suicide rate in my county is higher than the state rate; My healthcare practice does not ask the right questions about patients’ suicide risk.

  2. Which recommendation(s) from the plan do you want to follow to solve this problem?

  3. What do you want to be the final outcome? Briefly explain what will change when your project works. For example: My school will have a counselor available at least half time; A recognition and referral training appropriate for my community’s language and culture will exist; My county’s suicide rate will go down in the next two years; My practice will have appropriate questions about suicide risk in all forms, protocols and records.

  4. What resources do you already have for this project? These could be people who support your project or have the knowledge you need, materials and supplies, funding, space, technology, etc.

  5. What resources do you need? Is there anything else that might make it hard to succeed?

  6. What are the steps to completing your project? These are the things that need to get done in between starting and completing your project. For example, hiring a staff person, applying for funding or getting donations, finding meeting space, reaching out to elected officials, and learning more about how others have solved the problem.

  7. How will you evaluate your success? Will you use an evaluation tool you have, hire an evaluator or rely on project outcomes?

  8. How will you celebrate your success and thank those who helped?

25. Stone, D.M., Holland, K.M., Bartholow, B., Crosby, A.E., Davis, S., and Wilkins, N. (2017). Preventing Suicide: A Technical Package of Policies, Programs, and Practices. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

26. Nation, M., Crusto, C., Wandersman, A., Kumpfer, K. L., Seybolt, D., Morrissey-Kane, E., & Davino, K. (2003). What works in prevention: Principles of effective prevention programs. American Psychologist, 58, 449–456.

27. Washington State Suicide Prevention Plan: http://www.sprc.org/sites/default/files/Washington631-058-SuicidePrevPlan.pdf.

4C: Improve and expand evaluation of suicide prevention programs

Opportunities for Action Resources
Evaluate suicide prevention programs to monitor progress toward goals and whether interventions are having the desired effect. Preventing Suicide: A Technical Package of Policies, Programs,
and Practices
https://www.cdc.gov/violenceprevention/pdf/suicideTechnicalPackage.pdf
Suicide Prevention Resource Center—Program Evaluation
http://www.sprc.org/strategic-planning/implement-evaluate-improve
Regularly review program evaluation data to inform decision making around future program implementation. Gatekeeper training for suicide prevention: A theoretical model and review of the empirical literature
https://www.sprc.org/resources-programs/gatekeeper-training-suicide-prevention-theoretical-model-and-review-empirical
Bystander Intervention Model
https://umatter.princeton.edu/action-matters/care-others
The 9 Principles of Prevention
https://www.wcsap.org/prevention/concepts/9-principles-prevention
Use evidence-based practices in suicide prevention efforts. Suicide Prevention Resource Center Evidence-Based Prevention
https://www.sprc.org/keys-success/evidence-based-prevention
What Works for Health
https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health