Proposition 63 funded a variety of efforts to prevent suicide in California, including creating and expanding crisis services, delivering trainings, and disseminating suicide prevention messages to the state's diverse population. The authorizing body over these activities—the California Mental Health Services Authority (CalMHSA)—developed a strategic plan for implementing these Prevention and Early Intervention (PEI) programs that was guided by many values, one of which was to reduce racial and ethnic disparities in access to services. As a result, there have been efforts to develop programs that effectively reach out to California's culturally diverse populations, including those with limited English proficiency.
One component of this campaign was a statewide mass media effort titled “Know the Signs.” Through various media outlets, Californians are presented with the slogan “Pain Isn't Always Obvious” and encouraged to visit the campaign website (www.suicideispreventable.org) to learn about the warning signs for suicide and the resources available to help prevent it. Campaigns in English and Spanish were rolled out simultaneously from November 2012 to February 2013; both have a similar “look and feel” but were essentially developed independently of one another. A contractor that specializes in Spanish media campaigns oversaw the Spanish-language campaign messaging and tested it with a focus group consisting of Spanish-speaking parents.
As part of its evaluation of activities funded under Proposition 63, RAND conducted a statewide survey in the spring and summer of 2013 of 2,568 California adults ages 18 and older who were reachable by telephone (landline or cell phone). For the suicide prevention initiative, the survey was designed to estimate the proportion of Californians exposed to social marketing campaigns funded under Proposition 63, as well as to help decisionmakers better understand Californians' preferences for suicide crisis services and confidence in their ability to intervene with persons at risk of suicide. We initially surveyed a random sample of 2,001 adults in the spring of 2013 and then surveyed additional African American and Asian American adults that summer to enhance the diversity of the sample so that racial and ethnic differences could be tested. In total, the sample included 1,014 white, 631 Latino, 401 Asian American, and 360 African American individuals, as well as 108 individuals who identified as another race or with multiple racial or ethnic groups. Fifty-four respondents declined to report their races or ethnicities. Participants were allowed to choose the language of survey administration, including English, Spanish, Cantonese, Mandarin, Vietnamese, Hmong, and Khmer. A total of 305 Latino individuals completed the survey in Spanish; 254 Asian Americans completed it in an Asian language. We applied a weighting procedure to the data so that the results of the survey approximate those of the adult population of California. However, because our additional sampling of Asian Americans targeted Chinese and Southeast Asian subgroups, the views of Korean, Filipino, Japanese, or other Asian groups residing in California may not be fully represented.
Exposure to Messages
Thirty-nine percent of survey respondents reported being exposed to the Know the Signs campaign. Among both Latinos and Asian Americans, those who chose to take the survey in English were significantly more likely to report being exposed to the Know the Signs campaign. Specifically, nearly one-half of Latinos surveyed in English recalled seeing the slogan, while just over one-third of Latinos who completed the survey in Spanish reported the same. Among Asian Americans, 29 percent of those taking the survey in English reported being exposed to Know the Signs, but only 13 percent of those who took the survey in other languages also reported exposure (see Figure 1). When asked about exposure to suicide prevention media more broadly, more survey respondents in each group reported being exposed, but the difference between those taking the survey in English and in another language within racial and ethnic groups persisted.
The survey asked respondents, “If you were seeking help for suicidal thoughts and knew where to find resources to help, how likely would you be to use each of the following resources . . .” with a list of six available options (Table 1).* Latinos responding in English were more likely to report preferring any of the listed resources (93 percent versus 89 percent), specifically preferring visiting a website (73 percent versus 66 percent) and seeking face-to-face help from a counselor or mental health professional (77 percent versus 69 percent). Latinos taking the survey in Spanish were more likely to report that they would prefer to text a crisis line for support (60 percent versus 50 percent). Among Asian Americans, there were no statistically significant differences in preferring any listed resource, though English speakers were more likely to report preferring visiting a website (73 percent versus 49 percent), using web-based chat (54 percent versus 40 percent), and seeking face-to-face help from a counselor or mental health professional (82 percent versus 67 percent).
Table 1. Preferences for Help for Suicidal Thoughts, by Language of Survey Administration
|Percentage of respondents selecting different help sources in response to “If you were seeking help for suicidal thoughts and knew where to find resources to help, how likely would you be to . . .”|
|Resource Option||Total (%)||Latino||Asian American|
|English (%)||Spanish (%)||p||English (%)||Non-English (%)||p|
|Visit a website for information about suicide risk or resources||66||73||66||0.05||73||49||<0.01|
|Call a crisis line or hotline for advice about suicide risk and resources||62||63||66||0.50||55||47||0.18|
|Text a crisis text line for advice about suicide risk and resources||43||50||60||0.01||41||36||0.43|
|Go to a web-based crisis chat service for advice about suicide risk and resources||46||51||54||0.47||54||40||0.01|
|Seek help face-to-face from family members or friends||72||71||64||0.08||70||70||0.98|
|Seek help face-to-face from a counselor or other mental health professional||78||77||69||0.03||82||67||<0.01|
|Access any of the resources listed above||93||93||89||<0.01||94||88||0.20|
Note: “Likely” is defined as answering 1 or 2 on a scale that ranged from 1 (very likely) to 4 (very unlikely). P < 0.05 indicates significant difference between members of the same ethnic group based on results from a weighted logistic regression model.
Confidence to Intervene
Confidence to intervene refers to how competent a person feels to serve as a gatekeeper to identify, intervene, and refer people at risk for suicide to help. Seven questions were asked about confidence to intervene, with possible responses ranging from strongly disagree (1) to strongly agree (7). These items were then averaged for a total confidence score ranging from 1 (low) to 7 (high). As shown in Figure 2, while Latinos taking the survey in English reported greater confidence than those responding in Spanish (p < 0.001), there was no difference between Asian Americans taking the survey in English or one of the Asian languages in which it was offered (p = 0.20).
Our results show that suicide prevention messages in California are less likely to reach those who did not complete the survey in English (specific messages were developed for Spanish speakers, but there were no materials developed in any Asian language). Because these differences persist for both those who responded to the survey in Spanish and Asian languages, the difference among Latinos may reflect less on the reach and efficacy of the Spanish-language campaign and more on other factors that may influence awareness among those who did not complete the survey in English. We also found that resource preferences differ: For both Latinos and Asian Americans, those who did not complete the survey in English were less likely to prefer seeking a mental health professional for help. This may be because there is a limited capacity of providers who provide services that meet the language needs of clients.
As with any campaign that may increase demand for mental health services, increased outreach to non-English speakers should consider the supply of adequate referral sources to handle potential increased demand. In addition, efforts may be needed to increase knowledge about suicide and intervention strategies for Latinos who speak Spanish; to this end, CalMHSA-funded trainings in ASIST (Applied Suicide Intervention Skills Training) are being offered in Spanish throughout the state. RAND is conducting a follow-up survey (summer 2014) that will enable, among other goals, tracking further exposure to the Know the Signs campaign.
Becker, Amariah, and Rajeev Ramchand, Where Would California Adults Prefer to Get Help If They Were Feeling Suicidal? Santa Monica, Calif.: RAND Corporation, RR-681-CMHSA, 2014. As of August 1, 2014:
Ramchand, Rajeev, and Elizabeth Roth, Racial and Ethnic Differences in Exposure to Suicide Prevention Messaging, Confidence in One's Ability to Intervene with Someone at Risk, and Resource Preferences, Santa Monica, Calif.: RAND Corporation,
RR-682-CMHSA. As of August 1, 2014:
* The aggregate results for this question are presented in a separate fact sheet; see Becker and Ramchand, 2014. For results across all race and ethnic groups, see Ramchand and Roth, 2014.
This research was conducted in RAND Health, a division of the RAND Corporation.