| Abstract: | 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. |
