Suicide-related behaviours are relatively common among school-aged young people, and the associated individual, social, and economic impacts are considerable (Evans, Hawton, Rodham, Psychol, & Deeks, Reference Evans, Hawton, Rodham, Psychol and Deeks2005; Nock et al., Reference Nock, Borges, Bromet, Cha, Kessler and Lee2008). Such behaviours include suicide itself (ending one's life intentionally), suicide ideation (thoughts about engaging in behaviour that has the potential to end one's life), having a suicide plan (the formulation of particular means of ending one's life), and suicide attempt (engaging in risky behaviour in which there is at least some level of intent to die; Nock et al., Reference Nock, Borges, Bromet, Cha, Kessler and Lee2008). Globally, suicide is the leading cause of death among those aged 10–19 years (World Health Organization, 2014). Suicide ideation, suicide plans, and suicide attempts are even more common than suicide deaths. A systematic review of international literature on the prevalence of suicide and related phenomena in adolescents found lifetime prevalence rates of 9.7% and 29.9% for suicide attempt and ideation respectively (Evans et al., Reference Evans, Hawton, Rodham, Psychol and Deeks2005). While comparable data for adolescents are not available for suicide plans, data from a systematic review of adults in the United States aged 18 and older estimated the lifetime prevalence was 3.9% (Nock et al., Reference Nock, Borges, Bromet, Cha, Kessler and Lee2008).
In Australia in 2015, there were 145 young people aged between 15 and 19 who died by suicide, which corresponds to a rate of 9.8 per 100,000 young people. In keeping with past trends, rates were higher for young males than females (11.8 and 7.8 per 100,000 respectively; Australian Bureau of Statistics, 2016). While the number of suicides among young people is relatively few when compared to older age groups, suicide accounts for a sizeable proportion of deaths in this age group. In 2015, suicide accounted for 30.5% of deaths of Australians aged between 15 and 19 — specifically, 28.6% of deaths of males aged between 15 and 19 and 33.9% of deaths of females aged between 15 and 19 (Australian Bureau of Statistics, 2016). Given these statistics, it is not surprising that suicide is a significant concern for young people, with a national survey of close to 20,000 young Australians aged 15–19 years finding that one in five reported that suicide was a concern for them (Cave, Fildes, Luckett, & Wearring, Reference Cave, Fildes, Luckett and Wearring2015).
Schools are an appropriate setting for activities that aim to reduce the likelihood of suicide and for postvention activities (Robinson et al., Reference Robinson, Cox, Malone, Williamson, Baldwin, Fletcher and O'Brien2013). Postvention activities aim to ‘facilitate recovery after suicide, and to prevent adverse outcomes including suicidal behaviour’ (Andriessen, Reference Andriessen2009, p. 43). Given that youth suicides are more than twice as likely to occur as part of a cluster than adult suicides (Robinson, San Too, Pirkis, & Spittal, Reference Robinson, San Too, Pirkis and Spittal2016), and that schools are a common setting for youth suicide clusters (Haw, Hawton, Niedzwiedz, & Platt, Reference Haw, Hawton, Niedzwiedz and Platt2013), it is vital that schools respond quickly and appropriately after the suicide of a student in order to minimise distress and reduce the likelihood of a suicide cluster (headspace School Support, 2015). Programs frequently delivered in schools include universal education and screening programs targeting school students, and gatekeeper training programs designed to improve the ability of school staff to identify and refer students at risk of suicide (Katz et al., Reference Katz, Bolton, Katz, Isaak, Tilston-Jones and Sareen2013; Robinson et al., Reference Robinson, Cox, Malone, Williamson, Baldwin, Fletcher and O'Brien2013). Schools are also able to access a growing body of information and training support through internet-enabled online resources.
Despite the range and number of available services and programs, there is limited evidence regarding the appropriateness and effectiveness of interventions that can be delivered in school settings (Robinson, Hetrick, & Martin, Reference Robinson, Hetrick and Martin2011; Robinson & Pirkis, Reference Robinson and Pirkis2014). Although it is possible to conduct rigorous gold-standard evaluations of school-based suicide postvention programs, establishing a control group in these studies is challenging due to methodological and ethical considerations (Hazell, Reference Hazell1991; Robinson, Pirkis, & O'Connor, Reference Robinson, Pirkis, O'Connor, O'Connor and Pirkis2016). Due to the limited evidence regarding effective and appropriate suicide postvention supports for secondary schools, an expert consensus (Delphi) study was recently conducted (Cox et al., Reference Cox, Bailey, Jorm, Reavley, Templer, Parker and Robinson2016). Through several rounds of consultation with Australian and international researchers and practitioners in the suicide postvention field, the study led to the development of a set of guidelines to assist secondary schools and education systems to effectively respond to the suicide of a student, and to assess existing plans and procedures (headspace School Support, 2015).
In the context of this high level of need, headspace School Support (hSS) is a specialist and innovative service that assists secondary schools across Australia to prepare for and recover from suicide. The service provides evidence-based training, information and resources, including an evidence-based toolkit, as well as intensive support. hSS was developed in 2011 with funding from the Australian Government and forms part of headspace, Australia's National Youth Mental Health Foundation, which provides mental health support to young people aged 12–25 years throughout Australia via headspace centres and web-based support (McGorry et al., Reference McGorry, Tanti, Stokes, Hickie, Carnell, Littlefield and Moran2007; Rickwood, Webb, Kennedy, & Telford, Reference Rickwood, Webb, Kennedy and Telford2016). The primary service provided by hSS is postvention support, which includes advice and guidance around: informing staff, students, and parents about the suicide; managing media requests; identifying and responding to students and staff who are distressed; and planning for and managing memorials and anniversaries of the death. hSS also provides preparedness support, which aims to increase the extent to which secondary schools are prepared for a suicide. It does this through the delivery of evidence-based gatekeeper training using the Skills-based Training on Risk Management (STORM) approach (Robinson, Green, Spittal, Templer, & Bailey, Reference Robinson, Green, Spittal, Templer and Bailey2016) and workshops that focus on: building staff capacity around issues of suicide; developing (or refining) school policies and procedures around suicide; developing (or refining) an Emergency Response (ER) Plan; and assembling and managing ER teams. The Delphi study and resulting toolkit both affirms and informs this work (headspace School Support, 2015). In the 12-month period from February 1, 2015 to January 31, 2016, hSS was notified of 202 suicides and supported 1,172 schools. The service is increasingly well placed to ensure that schools are aware of its services and other supports to assist school communities.
This study had a number of aims. First, to determine the level of need for suicide postvention services in Australian secondary schools, awareness of the recently implemented School Support program, and perceptions and use of the internet for suicide information and support. Second, it aimed to determine satisfaction with and early impacts of the hSS service.
Method
The study involved two online surveys. The first survey involved school wellbeing coordinators from across Australia (referred to as the ‘School Wellbeing Staff Survey’). This explored the need for and awareness of the hSS service, and perceptions of the extent to which the internet is an appropriate and safe place for suicide information and support for staff and students. The second survey involved school representatives who had accessed the resources of and/or received support from hSS (referred to as the ‘Satisfaction Survey’). This explored satisfaction with and early impacts and outcomes of hSS. Both surveys were conducted in 2015.
Participants
School Wellbeing Staff Survey
A representative random sample of Australian secondary schools was selected using a sampling strategy that took into account schools’ state or territory, regional or remote location, and school type (government, independent, Catholic), comprising 924 schools in total. Each of these schools was contacted to invite the school wellbeing coordinator to take part in the survey. A complete, or partially complete, survey was returned by a representative from each of 23.2% (n = 214) schools. The majority of respondents indicated that their school was either in Victoria (26.6%) or Queensland (26.2%), followed by New South Wales (15.9%), South Australia (14.0%) and Western Australia (7.5%). There were 5.1%, 3.3% and 1.4% from Tasmania, the Australian Capital Territory and the Northern Territory respectively. This broadly reflects the state and territory breakdown of schools across Australia, with some overrepresentation of schools in Victoria, Queensland, South Australia, Tasmania, and the Australian Capital Territory, and some underrepresentation of schools in New South Wales, Western Australia, and the Northern Territory.
Analysis of school postcode data indicated that close to half of respondents (44.8%) represented schools in a major city, while 23.2% and 27.1% represented schools in inner regional and outer regional Australia respectively. Less than 5% of participants represented schools in remote or very remote Australia. The majority of respondents indicated that they occupied a student wellbeing role at their school (79.9%), while 14.5% reported that they were a principal or assistant principal. A further 2.8% reported that they were a teacher, while another 2.8% reported that they occupied a role other than those specified (administration and department head or coordinator roles). Most respondents worked in government schools (40.7%), while just under a third were from independent schools (32.4%) and just over one quarter were from Catholic schools (26.9%).
Satisfaction Survey
The satisfaction survey was sent to the 1,640 school representatives who accessed resources of and/or received support from hSS between November 1, 2013 and January 31, 2015 and had provided a valid email address. A complete (or partially complete) survey was returned by 21.9% (n = 359). Most respondents were from New South Wales and Victoria (36.3% and 24.0% respectively), followed by Queensland (17.3%), Western Australia (10.2%), and South Australia (7.9%). There were 2.6%, 1.2%, and 0.5% of respondents from Tasmania, the Northern Territory, and the Australian Capital Territory respectively. Analysis of postcode data indicated that more than half of respondents (56.5%) were from schools in a major city, while 19.8% and 17.1% represented schools in inner regional and outer regional Australia respectively. A total of 6.6% of respondents represented remote or very remote schools.
Most respondents (67.1%) indicated that they occupied a student wellbeing role (school wellbeing coordinator or staff member, school counsellor, school psychologist or chaplain). A further 22.8% indicated that they were a principal or assistant principal. Only a small percentage reported that they were a private health worker involved with a secondary school(s) (e.g., doctor, psychologist) or a teacher (5.2% and 2.8% respectively), and only 2.1% reported that they occupied a role other than those specified (administration and department head, coordinator and advisor roles). Respondents were asked about their main reason for using hSS, selecting from seven options. One quarter (25.4%) selected ‘to increase knowledge about, and capacity to respond to, a student suicide’; 22.6% selected ‘to participate in a workshop/meeting with an hSS staff member about steps [their] school could take to be better prepared for a future suicide’; 19.2% selected ‘a recent suicide(s)’; 16.4% selected ‘concerned a student(s) may be at risk of suicide’; 11.1% selected ‘general interest’; 3.9% selected ‘a recent attempted suicide(s)’; 1.4% selected ‘a recent death that was not suicide’.
Measures
The School Wellbeing Staff Survey consisted of 41 questions that measured: the extent to which respondents were aware of suicide support services for schools (including awareness of hSS specifically); the extent to which respondents felt they did (or did not) have appropriate skills, knowledge and support from their school to deal with suicide issues; the extent to which respondents felt schools do (or do not) require access to services that can assist with suicide issues; and use (or lack thereof) of the internet to access suicide-related information and programs to inform their work and as referral sources for students (please note these questions were about the internet in general, not specific services or websites).
The Satisfaction Survey consisted of 35 questions that measured: type of contact with hSS; helpfulness and appropriateness of each type of hSS service; perceived impact of hSS on preparedness, knowledge, skills and capacity with regard to managing suicide issues, including identifying and responding to students at risk; perceived impact of hSS on managing a suicide response (if relevant); perceived impact of hSS on how supported they felt managing a suicide response (if relevant); plans (if any) to use the service again if necessary; and whether they would recommend hSS to other staff and schools. Both surveys contained a range of question types including Yes/No responses, 5-point Likert scales (strongly disagree; disagree; neither agree or disagree; agree; strongly agree), and open-ended questions. All questions were developed specifically for the surveys by the research team and were based on the service's objectives and consultation with hSS managers.
Procedures
For the School Wellbeing Staff Survey, email addresses for the principals and school wellbeing coordinators of schools selected via the random representative sampling strategy were obtained via web searches or by contacting the schools directly. With the exception of government schools in one state/territory, the following opt-out procedure was used. Principals were emailed information about the survey in July 2015 and asked to respond within a week if they did not want the survey sent to their school's wellbeing coordinator. If principals did not opt out, the participant information sheet (which also contained the survey link) was emailed directly to the wellbeing coordinator. If principals did opt out, their school was replaced with another school using the same sampling strategy previously described. The ethics requirements of the education department in the remaining state/territory required an opt-in approach whereby principals of government schools in this state/territory were required to email the researchers if they agreed to the survey being emailed to their wellbeing coordinator. Two weeks after the survey was disseminated, two reminders were sent at fortnightly intervals to those who did not complete the survey. For the Satisfaction Survey, an email was sent to potential respondents in July 2015. This included the participant information sheet along with the survey link. Two weeks after the survey was disseminated, two reminders were sent at fortnightly intervals to those who did not complete the survey. Ethics approval was received from the University of Melbourne's Human Research and Ethics Committee and the governing bodies of government (n = 8) and Catholic (n = 21) schools across Australia.
Data Analysis
The Statistical Package for the Social Sciences (SPSS) version 21 and Tableau version 9.0 were used to store and analyse all quantitative data. Percentage endorsements for the survey items were calculated; valid percentages are presented, as missing data varied across the items; respective sample sizes are reported.
Results
Suicide Support Services for Secondary Schools: Need, Awareness, and Use
Almost half of school wellbeing survey respondents ‘agreed’ or ‘strongly agreed’ that suicide risk was a significant problem at their school (36.3%, n = 73 and 9.5%, n = 19 respectively). Only 6.5% (n = 13) ‘strongly agreed’ that they felt sufficiently skilled to work with students at risk of suicide (58.2%, n = 117 ‘agreed’ with the statement), while 12.4% (n = 25) ‘strongly agreed’ that they would know how to respond in the event of a student suicide (53.2%, n = 107 ‘agreed’ with the statement). Less than one fifth of school wellbeing survey respondents (17.9%, n = 36) ‘strongly agreed’ that they felt adequately supported by their school in their work with students at risk of suicide (55.7%, n = 112 ‘agreed’ with the statement). Almost all school wellbeing survey respondents (97.0%, n = 195) ‘agreed’ or ‘strongly agreed’ that it is important that their school has access to services that can provide support and assistance following a suicide or attempted suicide. Similarly, 96.0% (n = 193) ‘agreed’ or ‘strongly agreed’ that it is important their school has access to services that can provide support and assistance to reduce the likelihood of suicide.
Three quarters of school wellbeing survey respondents (75.1%, n = 160) indicated that they were aware of one or more suicide support service for schools in Australia. When asked specifically about hSS, more than half (59.2%, n = 126) reported that they had heard of the service. More than two thirds of these respondents (69.4%, n = 86) indicated that they or someone at their school had utilised hSS on one or more occasions. Approximately three quarters of school wellbeing respondents indicated that they regarded the internet as a useful source of suicide prevention information for school staff (75.0%, n = 141) and students (71.3%, n = 134). Most respondents (85.1%, n = 160) reported that they had used the internet to access information related to suicide prevention, and more than half (58.5%, n = 110) indicated that they had referred students to the internet to access online information about suicide and suicide prevention. Approximately three quarters of school wellbeing respondents reported that they thought the internet has potential to be a helpful and effective means of delivering suicide prevention programs to students (74.5%, n = 140), and more than half of respondents (51.1%, n = 96) reported that they had referred students to the internet to access online programs about suicide and suicide prevention. Less than half of school wellbeing respondents, however, reported that they had referred students to online counselling or therapy (46.8%, n = 88), or to interactive, self-guided intervention or treatment programs (46.3%, n = 87).
Satisfaction With and Perceived Impact of the hSS Service
Satisfaction Survey data indicated that hSS can have a positive impact on the knowledge, skills, and capacity of school staff with regard to suicide issues. The majority of respondents indicated that hSS had increased their knowledge about: services that can assist in dealing with a suicide death (83.8%, n = 274); how to respond to and manage a suicide death (81.0%, n = 265); suicide generally (75.5%, n = 247); and the signs and symptoms that someone at risk of suicide may exhibit (71.3%, n = 233). Similarly, the majority of respondents reported that hSS had increased their skills and capacity to: refer students in need of help to appropriate services (80.1%, n = 262); deal with future suicide deaths should they occur (78.6%, n = 257); respond to students at risk of suicide and related behaviour (76.1%, n = 249); respond to student distress (76.1%, n = 249); support students at risk (74.9%, n = 245); and identify students at risk of suicide and related behaviour (70.6%, n = 231).
Of Satisfaction Survey respondents who received preparedness assistance from hSS (N = 198), the vast majority reported that this had increased their knowledge about how their school should manage a suicide death (90.4%, n = 179), and helped them realise that there were steps their school should take to be better prepared for a suicide death (89.9%, n = 178). Over two thirds (69.2%, n = 135) indicated that they had developed or commenced work on a Suicide Postvention Response Plan following the preparedness assistance they received from hSS. Of Satisfaction Survey respondents who had used hSS following a suicide death (n = 63), the vast majority indicated that hSS had helped them/their school to manage the response (91.9%, n = 57), and helped them/their school to feel supported following the suicide (92.1%, n = 58). Nearly all Satisfaction Survey respondents (92.4%, n = 302) indicated that they would recommend hSS to other staff/schools, and most (81.8%, n = 266) reported that if a suicide tragedy occurred in the future, they would ‘definitely’ contact hSS for assistance.
Discussion
This study shows that suicide risk is a recognised concern for close to half of Australian secondary schools. It also reveals that there are gaps in the extent to which school wellbeing staff have the knowledge, skills, and capacity to manage suicide issues, and the extent to which they feel adequately supported by their school in their work with students at risk of suicide. Not surprisingly, therefore, the majority of school wellbeing survey respondents indicated that they think it is important that schools have access to services that provide assistance to reduce the likelihood of and increase knowledge of ways to respond to suicide.
The majority of school wellbeing survey respondents indicated they were aware of suicide services for secondary schools, including the hSS service. Results show that services such as hSS can increase perceived knowledge, skills, and capacity with regard to managing suicide issues, and increase the extent to which school staff feel their school is prepared for a suicide. A high percentage of respondents reported they had developed a Suicide Postvention Response Plan as a result of preparedness work they had undertaken with hSS. This is significant given recent research that found plans of this kind to be an important part of a school's suicide response (Cox et al., Reference Cox, Bailey, Jorm, Reavley, Templer, Parker and Robinson2016). In terms of postvention assistance specifically, the results show that services such as hSS can help schools to manage their response to a suicide and help schools feel supported following a suicide. Satisfaction with hSS was high, with nearly all respondents indicating that they would use hSS again and that they would recommend the service to other staff and students.
The results revealed that school wellbeing staff regard the internet as an appropriate and effective way of delivering suicide information and support to students and staff. Most school wellbeing survey respondents reported that they had used the internet in these ways, particularly for information. Acceptance of this medium is important because it vastly increases the reach and timeliness of suicide prevention and postvention information. hSS currently makes its resources available online, and this finding suggests it is important that the service continues to make its resources accessible in this way.
Recommendations
Given the receptiveness of school wellbeing staff to accessing suicide information and support via the internet, services such as the hSS service may want to explore the feasibility and desirability of increasing the extent to which they use it to provide schools across Australia with suicide prevention and postvention support, via means such as an online chat service for school staff, video conferencing, and webinars. This aligns with the mental health sector's increasing use of apps and online tools for the treatment of mental health problems (Calear & Christensen, Reference Calear and Christensen2010; Richardson, Stallard, & Velleman, Reference Richardson, Stallard and Velleman2010; Vogl, Ratnaike, Ivancic, Rowley, & Chandy, Reference Vogl, Ratnaike, Ivancic, Rowley and Chandy2016), which improve the reach and cost effectiveness of such interventions (Silenzio et al., Reference Silenzio, Duberstein, Tang, Lu, Tu and Homan2009; van Spijker, Majo, Smit, van Straten, & Kerkhof, Reference van Spijker, Majo, Smit, van Straten and Kerkhof2012). However, feedback from an optional open-ended question in the Satisfaction Survey indicated that the in-person and customised nature of hSS can be central to the perceived usefulness and impact of the service. Moving aspects of the service online could therefore jeopardise service satisfaction and impact. It would be important to conduct further qualitative and quantitative research before making such a move to ensure service satisfaction and impact would remain high.
Less than half of school wellbeing staff had referred students to online counselling services and this reveals an area for further development. With its integration with the headspace online counselling platform (eheadspace) and its close working relationship with school wellbeing and leadership staff, School Support is well placed to play a part in increasing the extent to which schools are aware of and refer students to online counselling services and information in addition to in-person services such as headspace centres. This seems important given online counselling is a growing alternative to in-person counselling due to its accessibility, interactivity, and anonymity (Burns, Davenport, Durkin, Luscombe, & Hickie, Reference Burns, Davenport, Durkin, Luscombe and Hickie2010).
Limitations
This study has several limitations that are important to consider. The Satisfaction Survey explored perceived impact of hSS on knowledge, skills and capacity, but did not explore actual impact on knowledge, skills or capacity, or impact on behaviour, as it did not employ a pre- and post-design. While this is not uncommon with real-world program evaluations (Bamberger, Rugh, & Mabry, Reference Bamberger, Rugh and Mabry2006), it is important to bear in mind. Furthermore, by necessity, the questions were developed specifically for the surveys as no suitable standardised measures were available; consequently, the reliability and validity of the questions are not assured.While every effort was made to direct the School Wellbeing Staff Survey to school wellbeing coordinators, some schools did not have someone in this role or this person was unable to complete the survey. In these cases, the survey was directed to the next most appropriate person at the school, which in some instances was the school principal or assistant principal. In these cases, reported awareness of and need for hSS may be lower than if the survey were directed to a staff member whose main role and responsibility was student wellbeing.
Conclusion — So What?
This study provides valuable insight into the extent to which school wellbeing staff across Australia feel it is important that they are adequately supported and skilled to deal with students at risk of suicide and respond following a suicide. It shows there are gaps in the knowledge, skills, and capacity of school wellbeing staff that services such as hSS can help fill. It also shows that schools are receptive to the provision of internet-based suicide information and support for students and staff, though it was noted that the in-person and customised nature of hSS can be central to perceived usefulness and impact of the service. The hSS service was valued and well accepted according to respondents who had been involved with it, and the service was shown to increase perceived knowledge, skills, and capacity with regard to suicide issues. Demonstration of these outcomes is an important first step in building the limited evidence with regard to interventions that can be delivered in school settings. Further research investigating the appropriateness and effectiveness of hSS is required, as it is clear that Australian secondary schools need and value such support, and international interest in this world-first service suggests it could be a useful model for secondary schools outside of Australia as well.
Acknowledgments
The authors wish to acknowledge the governing bodies of government and Catholic schools that provided approval and support for the research to be undertaken in their state or territory, and the schools across Australia that took part in the surveys.
Financial Support
Dr Jo Robinson is funded by a NHMRC Early Career Fellowship. headspace National Youth Mental Health Foundation is funded by the Australian Government.
Competing Interests
All authors have been employed by or directly involved with headspace National Youth Mental Health Foundation.
