QPR for Any Culture: the mass customization of a public health gatekeeper training program
Paul Quinnett, Ph.D.
Kira LaCompte, M.S.
(updated 12/22/06)

If the person most likely to prevent you from taking your own life is someone you already know, one question becomes immediately relevant to your survival: Of the people you know, how many know what to do if you become suicidal and send them a warning sign?

In keeping with the Surgeon General’s 2001 recommendations for gatekeeper training, QPR (Question, Persuade, and Refer) is a widely-taught suicide prevention gatekeeper training program designed to train ordinary citizens to provide an immediate, bold intervention to produce a pre-determined result when a suicide warning sign is recognized: as quickly as possible, accompany the suicidal person to a professional for assessment and care (Quinnett, 2005).

The purpose of this training is to do for suicidal people what CPR does for persons in cardiac arrest. The most common reason people die from cardiac arrest outside of hospitals (when the heart suddenly stops beating) is that no one nearby knows CPR (American Heart Association, 2005). The greatest danger to someone in cardiac arrest is bystander inaction. Similarly, research has shown that the most common response to someone in a suicide crisis is also significant other inaction (Wolk-Wasserman, 1986).

Of the more than 300,000 Americans who die each year from cardiac arrest, it is estimated that 75 to 80 percent of them die outside of a hospital. The odds of surviving such a medical crisis are doubled if someone nearby responds quickly an effectively with CPR, and in the Seattle Washington, King Country area where approximately one-in-four adults has been trained in CPR, survival rates are dramatically greater than in comparable urban areas (Sanddal, et. al., 2003).

Similarly, the majority of suicide victims die outside of hospitals. If the odds of survival from a suicide crisis are to be improved where these self-inflicted deaths most frequently occur (at or near home, work or school), more people must know what to do when suicide warning signs are observed.

Using the model of CPR training as successfully distributed to a large number of people in a defined population, the goal of the QPR Institute and its licensed instructors is to train at least one in four adults in QPR, or at least one adult member of every family in America. Youth, because their friends often recognize both risk factors and suicide warning signs (Moskos, et. al., 2005), are also targeted for training, as are more traditional gatekeepers in schools, colleges and worksites. Such a massive educational program would provide suicidal people in a life-threatening crisis at least some chance of being rescued by those around them. This is a very ambitious goal, but one we believe will save lives. The challenge is three fold:

  1. Does QPR actually work?
  2. Can it be taught successfully so that gatekeepers actually carry out the three step intervention?
  3. How can QPR be taught to the millions of persons necessary to provide timely interventions to the estimated 775,000 non-fatal attempters, and approximately 30,000 Americans who complete suicide each year?

But before the last two questions can be answered across the wide, multi-cultural landscape of North America, the intended audience must be able to accept the message that suicide is preventable and that educated gatekeepers can apply something like QPR to help save lives.

Culturally competent gatekeeper training
Suicide is not an easy word to use or even say. English in origin, some cultures do not have a ready translation. Thus, suicide prevention education is immediately challenged where there is no common meaning or understanding of what the term means or how suicide should be discussed. For a concept like QPR to be effective in multiple cultures and in multiple languages, it must somehow successfully pass through the cultural filters that might otherwise keep the message from reaching the potential gatekeeper audience.

The acronym was selected for the following reasons: easy to remember, rhymes with the universal CPR, and each letter is a core idea and act common to all human interactions. Therefore, QPR should be translatable into multiple languages and cultures and produce similar results.

Like the marketing of a Subway™ sandwich or a cup of Starbucks™ coffee, the acceptance of QPR gatekeeper training depends, in large part, on subgroup and individual receptivity to the “look and feel” of the intended public health message. To encourage stakeholder acceptance of QPR training, the research supported core training content must be delivered in culturally acceptable packaging. Just as Starbucks provides the basic coffee beans and coffee, the consumer customizes drink, e.g., “Double tall latte, low-fat.” If Starbucks can travel well worldwide, can a suicide prevention gatekeeper training program do likewise?

A first cultural test
With the help of the Aberdeen Area Indian Health Service, the multi-cultural original QPR trigger video was re-shot with all Native American people, symbols, stories and Indian music. This nine minute review of QPR and its purpose precedes the 21-slide core curriculum required in the standard delivery program. The video was converted to DVD format and made available to QPR Instructors throughout North America and additional copies are being distributed to a variety of Native American tribes and leaders.

The original story lines, speakers, images, and script for the QPR video was developed with a multidisciplinary public health and mental health team as well as community representatives who served on the Spokane County Health Department Task Force on Suicide Prevention in 1999. The original film was produced by North by Northwest of Spokane, Washington, and funded through an unrestricted grant from Eli Lilly and Company. Now in digital format, the original video content was provided to Kat Productions of Billings, Montana, which allowed splicing and editing of the original video with the new, Native American version. The project was funded by the Aberdeen Area Indian Health Service.

The co-author, Kira LaCompte, recruited the various speakers and oversaw the project to completion, nothing that this version of the video might represent northern plains tribes; it might not work well for others in other parts of Indian Country. However, tribes from many areas of America have now seen the new video and reception has been very positive.

By recruiting Native American people to tell their own stories, we were able to put a “familiar face” to suicide in the Aberdeen Area. Although most adults know someone or have been personally impacted by suicide, having Native American people give their perspective on suicide on the trigger video immediately grabs the attention of the gatekeeper classes and opens up communication. This video helps to accomplish the goal of reducing the stigma of suicide and mental health issues.

A similar re-shooting of the QPR trigger video for African-American viewers was completed in late 2006 and other cultural groups and organizations have expressed interest as well, including police, firemen, and emergency services personnel. As is well known, these are well established sub cultures.

Marrying mass customization with the World Wide Web
The new Indian Health Service video was compressed into digital format and uploaded into the current QPR online gatekeeper training program offered by Eastern Washington University. In this format American Indians and First Nations people from all over North America and Canada can select the Native American option of QPR training online (anytime and anywhere a high-speed internet connection is accessible) and, upon viewing the video content, will see the faces and hear the names of other Indian peoples telling their stories while expressing their views about suicide and the need for prevention education.

Likewise, as additional versions of the trigger video are produced, the menu of cultural selections will grow. Programmers are able to take still images from the video and integrate them into the other text files so that, from a “look and feel” point of view, the entire program appears a seamless presentation of one’s own culture.

Can online delivery of QPR gatekeeper training help?
Research on the effectiveness of QPR is ongoing and the results of a major random clinical trial are forthcoming in 2006 and beyond. Evaluations to date of learner acquisition of knowledge and retention of the QPR steps are positive and, overall, gatekeeper training is determined to be a “promising” intervention, both in terms of timely interruption of an unfolding suicide crisis, but also in detecting and referring new cases of potentially suicidal victims for treatment (Quinnett, 2005).

As to training hundreds to save one, thousands to hundreds, and millions to save thousands, and as of the end of 2006, the QPR Institute had trained 3008 Certified Instructors to teach QPR in traditional, face-to-face classroom settings in more than 45 states. While some of these instructors trained delivered little or no training following certification, others provided a great deal.

Based on the volume of QPR booklets and cards printed and distributed to these instructors nationwide, approximately 10,000 adults are now being trained each month using traditional learning methods, with the total number of adults trained since program inception exceeding 300,000 at the end of 2005. Other suicide prevention programs are also training gatekeepers; how many is not known.

To facilitate the teaching of QPR to thousands of gatekeepers a day instead of thousands a month, a review of the literature was undertaken of what has variously been called e-learning, distance learning, online learning, or Web-based education. A summary of the research comparing e-learning verses traditional instruction is instructive.

Overall findings from a number of studies (cited below) are positive and that e-learning students:

Overall, e-learning achieves consistently better results compared to traditional classroom settings, and also provides considerable savings in time, money, hassle-factors (e.g., parking, congested city travel, baby-sitting, etc.), and in direct transportation costs.

Time savings
After a comprehensive review of more than 40 studies, Fletcher (1990), found a reduction in time spent to master the same material ranged from 20-80 percent, with most savings between 40-60 percent. These findings have been confirmed by a number of other researchers as well (Adams, 1992, Cantwell, 1993, Bradley, 1994, Hofstetter, 1994, and Hall, 1997). Of note, none of the investigators found a decrease in training effectiveness in terms of retention and transfer of learning.

Convenience
As suicide prevention education moves from optional to mandatory, service organizations with 24/7 staff, multiple locations, or rural and remote sites will find dramatic cost savings in the delivery such training via the internet which, in many ways, translates into greater acceptability of training and greater ease in carrying out institutional suicide risk reduction practices.

With increasing access to broad band internet connections throughout America, access barriers to high-value multimedia, interactive educational programs are disappearing, thus reducing resistance to the cost of suicide prevention education.

To further increase acceptance of e-learning, researchers have shown that travel and entertainment costs associated with traditional training can be cut by at least 50 percent and as high as 80 percent (Hall, 1997, Hemphill, 1997). These are no small savings for budget-minded leadership responsible for public health education. Given these savings, continued justification for traditional classroom training becomes increasingly difficult to defend.

Also, because e-learning can be asynchronous, flexible, self-paced, and taken anywhere at anytime, it is perfectly suited for training employees in large, multi-sited organizations, those with 24/7 employee shifts, and those with staff working in their homes. With suicide rates highest in rural and frontier America, perhaps the only practical and cost-effective approach to suicide prevention education is the use of the internet, as all other options are far too costly, inconvenient and impractical.

Standard core program, but with customization in a cultural context
The QPR online training includes a media-rich blend of video, text, voice over lecture and survey, quiz, and evaluation components that require learner participation to complete and earn a printable certificate of course completion. Available over any high-speed internet connection, the program is delivered with perfect fidelity each time. Host organizations can also tailor and customize elements of the program with regard to referral and resource information, e.g., local crisis telephone numbers, maps to counseling centers, and other key instructions to gatekeepers regarding organizational policy and procedures.

Each gatekeeper trained also has the option of exploring areas of special interest (files, Web links, and free telephone consultation with certified crisis response hotlines). These elements are included in the online program to enhance the participant’s sense of competence and self-efficacy in carrying out the referral portion of the QPR intervention. A downloadable role-play and instruction sheet is also available for recommended practice and rehearsal.

Also, QPR delivered online allows learners to activate the program once via a unique access code, but then re-enter the program as many times as desired over a three-year period, or longer depending on the option purchased. For employers, a lifelong subscription is available at reasonable cost. Thus, periodic reviews of training or on-demand access (in the event the gatekeeper encounters someone suicidal and wishes to review the action steps) are always available via any available internet connection.

To further individualize training, special files exist for various at-risk groups and learners can be provided customized content by their employer or host organization that have elected to customized the program. For example, a recent program update included a file for primary care providers screening for suicide in medical settings.

Face-to-face support
To expand training opportunities for existing Certified QPR Instructors, and to bolster the QPR online learning experience, participants may also meet with Certified Instructors for Q&A periods, role-plays and detailed review of organizational policy and procedures regarding referral resources and mechanisms. Other behavioral healthcare professionals and college professors can also provide follow-on face-to-face practice sessions and referral information. This model may also be expanded to include online training followed by video-conferencing technology.

The future
As an economical and efficient option to traditional face-to-face learning, QPR online gatekeeper training will continue to develop as an e-learning program. Since suicidal behavior occurs in cultural, social, religious, ethic and racial contexts, customization of “look and fee” of this training program is critical to its wide acceptance and to breaking down fear, stigma and other pre-existing barriers to suicide prevention education.

Summary
Clear evidence now exists that suicide can be prevented. Gatekeeper training is one promising strategy to prevent premature death or injury by suicidal behaviors. Culturally competent online gatekeeper training which raises awareness, enhances recognition of suicide warning signs, leads to a reduction in risk factors and an enhancement of protective factors -- and which teaches a basic, practical, intervention in a cost-effective and efficient manner using the latest in Web-based technologies -- is a public health intervention whose time has come. The prevention of suicide is too important to be left to traditional, slow-evolving, monolithic, institutionalized classroom models of education and training. Absent an aggressive research and technology-transfer agenda to evaluate the merits of e-learning technologies in the prevention of suicide, countless lives will be lost worldwide that might have been saved.

References
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