Nationwide telephone survey
Telephone surveying has the benefit of accessing a large sample in an efficient manner. Further, the use of the Kish selection grid (to select a random person in households with several residents) and the computer-generated telephone numbers ensure that the sample is drawn from all persons with a telephone. The large number of participants and the representativeness of the sample allow a reliable estimation of the current knowledge and attitudes concerning suicidality in the German population. Thus, content and material of the online intervention can be adapted precisely.
The SOSS-SF and the LOSS-SF are tools to measure suicide stigma and suicide literacy. Since there are no validated instruments measuring suicide stigma and suicide literacy in German, they were translated, culturally adapted, and applied for the first time in the European region. Further, the instruments were used for the first time with a representative sample and via telephone.
As the survey is conducted in Germany, conclusions can only be drawn for the German speaking residential population and data cannot be generalized to other countries. Because suicidality is a very sensitive and taboo topic and telephone interviews may be considered impersonal, socially desirable answers are possible. Further, we cannot rule out a selection bias due to the exclusion of persons with neither a landline nor a cell phone—although the proportion of households with telephone in Germany is high (90.9% landline, 95,5% cell phone [
60]).
E-mental health interventions
All German-speaking adults with internet access can participate in the online intervention. The material provided in this online intervention is developed trialogically [
50,
51], following a structured process with high quality standards. Thus, high quality and evidence-based content will be provided. This addresses a major weakness of some existing suicide preventions sites: A Canadian study found that over half of the statements on such websites were not evidence-based [
61]. A more recent study evaluating search engine results when searching for help in a suicidal crisis [
62] found that irrelevant websites are identified as well as websites expressing mixed or neutral attitudes towards suicide, or even pages which can be considered as harmful, e.g. describing lethal methods [
63].
The online information and the online intervention aim to reach as many participants as possible without exclusion. Therefore no specifc target-group is defined, which is different to the Australian project which focused on male farmers aged 30–64 but did not exclude anyone over 18 years. However, material will be tailored to participant’s experience of suicide: persons who attempted suicide, persons having suicidal thoughts, persons who fear losing someone by suicide, and persons who have lost someone by suicide. Further, evidence-based information on factors that influence suicide risk—such as migration background, serious physical diseases, or sexual orientation—will be provided.
Nevertheless, when a specific population is addressed, life situations of the target group can be taken into account more precisely. Thus, material is adapted for example in terms of language or images (e.g. special design characteristics for young people) and the target group can be contacted in their environment. In the Australian project for example, information on the project was provided via farmer associations and images depicted the type of farming the participants identified with [
31].
Selecting a survey tool was difficult, given limited availability of well-evaluated suicide stigma scales measuring self-stigma and perceived-stigma. We wonder if stigma scales may have the effect of reproducing or reinforcing stigmatizing attitudes. While stereotypes, prejudices, and discrimination already exist in society, will answering suicide stigma scale items exascerbate negative beliefs about the self, the world, or the future? Will participants react to stereotypes presented in the phone survey? Moreover, will participants who previously experienced minimal stigma experience an increased belief that people may devalue them because of a mental health crisis?
Our decision to use the SOSS-SF [
46] has been based on the ability to compare results with the Australian project
The Ripple Effect [
31]
—research that has informed the development of our online intervention. We will add a new instrument to measure self-efficacy expectations of dealing with psychologically difficult situations in order to explore the online intervention’s potential to empower users. Whether a short online intervention can change self-efficacy expectations, which may interrelate with the stable trait of participant’s general self-efficacy expectations, remains to be seen.
Although the online intervention is not a substitute for a professional mental health consultation, it can reach persons with limited access to health care (e.g. in rural areas). Furthermore, people who refuse to seek out traditional services, especially those who fear being hospitalized or taking medication, may utilize technology-based mental health services [
64]. Thus, the online intervention serves as an opportunity to inform participants about suicidality and to improve health behaviours with reduced barriers.
Presumably, the intervention will most likely reach people who are seeking information about suicidality on the internet. This self-selection is likely to exclude people who are not looking for this information, which may be confounded by particular characteristics of the groups. Although the provided materials will have an engaging and interactive design (e.g. through the use of videos, digital postcard messages, and simple phrasing), the intervention has a quite academic nature. The intervention may be used by persons who have been mentally strained for a long time with extensive internet research experience. These persons may already have high mental health literacy and further improvement, through intervention participation, may lead to a ceiling effect.
The intervention targets participants who, on the one hand, want to deal with suicidality but, on the other hand, are currently not suicidal. In an acute crisis, the intervention does not provide crisis support and may be inappropriate (which is clearly emphasized during the intervention).
The required login to the intervention has advantages and disadvantages. On the one hand, it offers protection of the material as well as assistance with managing the data. On the other hand, the login might also be a barrier to participation.
Due to the exploratory design of the study and the goal to provide an intervention that is accessible and available for all interested parties, a randomized controlled design will not be conducted. Given this, changes in knowledge and stigma will not be causally attributable to the intervention. To test whether this intervention is more or less helpful than no or another intervention, randomized controlled trials are recommended for future research. Future research may also consider revising the intervention content after accounting for the results of this study. After revision, persons interested in the intervention (e.g. a target group of interest identified by this study) could be randomly assigned either to a waitlist control group or an intervention group.
Development of the online material has been conducted in a trialogical exchange process of experience. The collaborative involvement of persons with an experience of suicide in videos and written messages provides credible and relevant content, e.g. the personal reports show that other persons can be in a similar life situation and how they have dealt with their situation. In order to reduce stigma, to increase awareness, and lift the taboo on suicidality, it is important that various parties shed light on the complexity of the phenomenon of suicide. An intervention based on the guiding principle of trialogue presents the perspective of persons affected by suicide as equal to expert opinions and thus emphasizes knowledge and abilities as well as autonomy and maturity of people seeking help. This can be considered as a strength of the project.
The online intervention targets cognitive, emotional, and behavioral components: psychoeducative text material addresses the participants on a cognitive level, whereas personal video stories and written messages about lived experiences of suicide can address participants emotionally. Finally, the personal goal setting and the possibility to leave own digital post cards can stimulate participants into taking action. A recent review includes fourteen e-mental health studies aiming to reduce symptoms associated with suicidality (e.g. suicide ideation, self harm). The online interventions were associated with reductions in suicide ideation at post-intervention. However, only five studies included in the review were developed specifically for self-management of suicidal ideation; the majority of the programs was developed for self-management of depression [
65]. Besides
The Ripple Effect to our knowledge, no other e-mental health approaches to reducing suicide stigma have been conducted to date. Thus, this project will provide important information about the effectiveness of online interventions aiming to reduce suicide stigma and increase suicide literacy.