The US Air Force Suicide Prevention Program: Implications for Public Health Policy

Objectives. We evaluated the effectiveness of the US Air Force Suicide Prevention Program (AFSPP) in reducing suicide, and we measured the extent to which air force installations implemented the program.Methods. We determined the AFSPP''s impact on suicide rates in the air force by applying an intervention regression model to data from 1981 through 2008, providing 16 years of data before the program''s 1997 launch and 11 years of data after launch. Also, we measured implementation of program components at 2 points in time: during a 2004 increase in suicide rates, and 2 years afterward.Results. Suicide rates in the air force were significantly lower after the AFSPP was launched than before, except during 2004. We also determined that the program was being implemented less rigorously in 2004.Conclusions. The AFSPP effectively prevented suicides in the US Air Force. The long-term effectiveness of this program depends upon extensive implementation and effective monitoring of implementation. Suicides can be reduced through a multilayered, overlapping approach that encompasses key prevention domains and tracks implementation of program activities.Although much is known about risk factors for suicide, there are few examples of multifaceted, sustainable programs for reducing morbidity and mortality attributable to suicide and suicidal behaviors. The Air Force Suicide Prevention Program (AFSPP) has been found to have achieved significant relative risk reductions of rates of suicide and other violence-related outcomes, including accidental death and domestic violence.¹ The AFSPP, now in its 13th year, is an example of a sustained community-based effort that directly addresses suicide as a public health problem.The AFSPP, launched in 1996 and fully implemented by 1997,¹ emphasizes leadership involvement and a community approach to reducing deaths from suicide. The program is an integrated network of policy and education that focuses on reducing suicide through the early identification and treatment of those at risk. It uses leaders as role models and agents of change, establishes expectations for airman behavior regarding awareness of suicide risk (i.e., policymaking), develops population skills and knowledge (i.e., education and training), and investigates every suicide (i.e., outcomes measurement). The program represents the air force''s fundamental shift from viewing suicide and mental illness solely as medical problems and instead seeing them as larger service-wide community problems (Gen T. S. Moorman Jr, US Air Force, personal communication, June 2001).The program''s approach is predicated on current knowledge that individuals at risk exhibit warning signs and that intervention at an early stage lowers risk and results in improved outcomes. Thus, the program aims to reduce stigma and encourage early help-seeking behavior by changing social norms through education and policy. This is achieved at the community level by changing the community''s knowledge, values, beliefs, attitudes, and behaviors concerning distress, help-seeking, and suicide. The AFSPP affirms and encourages help-seeking behavior, normalizes the experience of distress, promotes the development of coping skills, fights the stigma associated with receiving mental health care, and educates the community about the absence of negative career consequences for seeking and receiving treatment. The program also seeks to improve outcomes in putative distal risk factors for suicide, including family violence, alcohol and substance use, diminishing work performance, and depression. The result over the years has been the creation of an atmosphere of responsibility and accountability for reducing deaths from suicide that includes new expectations for behavior at the community and individual levels.With little theoretical guidance available in 1996 to shape the program, the air force developed an overlapping programmatic design, resulting in far-reaching enhanced capacity of organizational responsiveness in critical areas at multiple levels. These overlapping components became known formally as the 11 Initiatives of the Air Force Suicide Prevention Program, which are described briefly in the box on the next page and in detail online (AFPAM 44–160; available at http://afspp.afms.mil/idc/groups/public/documents/afms/ctb_056459.pdf).We studied the effect of the AFSPP on air force suicide rates from 1997, when the program was fully implemented, through 2008. We examined rates in the context of a 27-year period, from 1981 through 2008, during which time there have been 3 military conflicts and a major downsizing of the air force during the early 1990s. This 27-year period provides an important historical perspective on suicide rates in an organization that underwent rapid, widespread change in force structure and that dealt with the onset and continuation of Operation Enduring Freedom in Afghanistan in 2001 and Operation Iraqi Freedom in 2003. We also conducted a naturalistic experiment from 2004 through 2006, when we measured the implementation of program components during and after a transient increase in suicide rates.     

Public Policy

No abstract available for this article.     

Public Participation in the Process of Local Public Health Policy,Using Policy Network Analysis

Objectives:

To assess the current public participation in-local health policy and its implications through the analysis of policy networks in health center programs.

Methods:

We examined the decision-making process in sub-health center installations and the implementation process in metabolic syndrome management program cases in two districts (‘gu’s) of Seoul. Participants of the policy network were selected by the snowballing method and completed self-administered questionnaires. Actors, the interactions among actors, and the characteristics of the network were analyzed by Netminer.

Results:

The results showed that the public is not yet actively participating in the local public health policy processes of decision-making and implementation. In the decision-making process, most of the network actors were in the public sector, while the private sector was a minor actor and participated in only a limited number of issues after the major decisions were made. In the implementation process, the program was led by the health center, while other actors participated passively.

Conclusions:

Public participation in Korean public health policy is not yet well activated. Preliminary discussions with various stakeholders, including civil society, are needed before making important local public health policy decisions. In addition, efforts to include local institutions and residents in the implementation process with the public officials are necessary to improve the situation.     

Families,Care of the Handicapped,and Public Policy

No abstract available for this article.     

End-of-Life Care Issues: A Personal,Economic, Public Policy,and Public Health Crisis

Advance directive documents are free, legal, and readily available, yet too few Americans have completed one. Initiating discussions about death is challenging, but progress in medical technology, which leads to increasingly complex medical care choices, makes this imperative.Advance directives help manage decision-making during medical crises and end-of-life care. They allow personalized care according to individual values and a likely reduction in end-of-life health care costs.We argue that advance directives should be part of the public health policy agenda and health reform.IS END-OF-LIFE CARE A MATTER of personal values, economics, public policy, or a looming public health crisis? Actually, it is all of these. But when we consider the population’s demographic shift to older adults, which is associated with chronic illness and multiple comorbidities, the enormous health care costs consumed in end-of-life care, and complex ethical issues, it is time for the public health community to put this issue squarely on its agenda. Increasing the rate of completion of advance directives is a key step, and specific policy strategies can be identified to accomplish this objective.Advance directives were created by federal and state law to ensure autonomy of patients who eventually become unable to make decisions for themselves.1,2 Advance directives are free, legal, and straightforward forms that can be completed in a few minutes. Typically, advance directives address several areas regarding end-of-life care when a person becomes unable to make medical decisions for himself or herself. First, a person defines the amount and kind of care he or she might receive under various medical circumstances. Second, a person designates a health care agent to make medical decisions when the person can no longer do so. Third, advance directives may also address other end-of-life care issues including organ donation, whole body donation to medical schools, funeral and burial arrangements, legacy recordings for posterity, and—in 3 states (Oregon, Washington, and Montana)—assisted dying.     

Public Policy and Hospital Marketing

No abstract available for this article.     

Obesity,Health at Every Size,and Public Health Policy

Obesity is associated with chronic diseases that may negatively affect individuals’ health and the sustainability of the health care system. Despite increasing emphasis on obesity as a major health care issue, little progress has been made in its treatment or prevention. Individual approaches to obesity treatment, largely composed of weight-loss dieting, have not proven effective. Little direct evidence supports the notion of reforms to the “obesogenic environment.” Both these individualistic and environmental approaches to obesity have important limitations and ethical implications. The low levels of success associated with these approaches may necessitate a new non–weight-centric public health strategy. Evidence is accumulating that a weight-neutral, nutrition- and physical activity–based, Health at Every Size (HAES) approach may be a promising chronic disease-prevention strategy.Obesity is defined as having a body mass index (BMI; defined as weight in kilograms divided by the square of height in meters) in excess of 30. Obesity is associated with numerous chronic health conditions, including diabetes, hypertension, heart disease, and certain cancers.1 The directionality of such associations is largely unknown, confounding may be present, and causality has only definitely been assigned to obesity with respect to osteoarthritis and ovarian cancer.2 Despite these limitations, to counter the health effects of obesity-associated conditions, individuals frequently are encouraged to lose weight to improve individual and population health. However, diet-induced weight loss stimulates somatic and psychological ‘homeostatic pressures’ that induce weight regain.3 These mechanisms include hormonal alterations, reduced satiety and energy expenditure, and increased hunger.3,4 These adaptations stimulate weight regain in more than 90% of weight losers.5,6 In acknowledgment of the limited effectiveness of individual approaches to weight loss, increasing emphasis has been placed on environmental reforms. However, when weight loss is the key motivator of such changes, they are hindered by a limited evidence base and ethical difficulties. These concerns suggest public health would benefit from a shift in focus from weight loss to disease prevention for individuals of all ages and sizes, with a focus on health rather than weight-loss outcomes, and environmental reforms devoted to enhancing livability, accessibility, and equity. Evidence is accumulating that a weight-neutral, nutrition- and physical activity–based, Health at Every Size (HAES) approach may be a promising chronic-disease prevention, and overall well-being, strategy.