The evaluation of SyS Data Sharing for School-Based Suicide Prevention Initiative is driven by the qualitative information gathered via these innovative public health and school district partnerships. By meeting our first objective, to establish communication channels with school district partners, we learned that our school partners largely rely upon self-report (from student or parent) to gather and track suicidality in their districts. Access to non-fatal hospital level data was one missing piece of the overall picture of youth suicide which the SyS Data Sharing for School-Based Suicide Prevention Initiative fills to provide a more comprehensive understanding of youth suicide in school districts. By approaching these partners with more questions than answers, we allowed for a creative collaborative process resulting in an information sharing practice which will be most useful and sustainable going forward for all stakeholders.
We were able to meet, present, and gather initial feedback with eight school district partners representing four unique school districts. Staff from these school districts included the Chief Health Officer, Director of Community Partnerships for Crisis Intervention, Director of Social, Emotional and Behavioral Services, and the Prevention and Crisis Recovery Coordinator. In the three initial meetings we held over the summer break, we provided education about SyS data and how the data can be utilized, and we empowered our school district partners to understand, explain, and request this data. We emphasized the ability of our system to provide both timely data alerts to enhance situational awareness as well as historical trends of non-fatal suicide-related ED data in the SyS system to provide an overview for the district. For example, TCHD SyS provides weekly notification reports for regional updates on health indicators of interest1, including COVID-19, suicidal ideation, and suicide attempts.
Of those four initial school district contacts, we confirmed corresponding school district zip codes with two of those districts, which allowed us to begin monitoring and sharing data for those two confirmed districts within the National Syndromic Surveillance Program's (NSSP) Electronic Surveillance System for Early Notification of Community-Based Epidemics (ESSENCE). We set up two queries for each school district to monitor ED visits related to suicidal ideation and suicide attempt. These CDC-validated case definitions for suicidal ideation and suicide attempt search ED records using their chief complaint (free text) and discharge diagnosis fields (ICD-10 codes) for terms and codes which meet the case definition criteria. TCHD validated these definitions in 2020 (CDC Suicide Attempt v1) and 2021 (CDC Suicidal Ideation v1) to enhance accurate monitoring of suicide-related trends in our surveillance system. By using exponentially-weighted regressions based on the most recent four weeks of data, the ESSENCE system calculates an expected number of visits related to suicidal ideation or suicide attempt and compares that value to the actual observed number of visits related to the specified suicide indicators that week or time period. When the observed value exceeds the expected value with statistical significance, calculated within the ESSENCE system, the system provides a notification via email so that the alert and its associated cases can be reviewed. This alert is what is used to develop an alert notification report to summarise the aggregated cases in a meaningful and actionable way for our school district partners.
We developed the alert notification report coding in RStudio to run descriptive statistics and visualization and finished the report template in Microsoft Publisher. We developed three report examples using TCHD local aggregated information to share with partners during the initial meetings. The alert notification reports were organized into two sections: a background section and results section. The background section included information regarding the population of interest and the definition information used to identify cases (e.g. CDC Suicidal Ideation v1). The results section included a written summary of the alert - how many cases were identified or what percent of ED visits were related to the specified suicide indicator which triggered the alert and over which time period (weekly data). For visualization, the report included a trendline for the most recent eight weeks of data, displaying percent of ED visits related to the suicide indicator among youth residents of zip codes corresponding to the specified school district and a mark to identify the week during which the alert took place. Additionally, in the results section, we provided a data table which provided stratification by sex and by age group (0-9 years, 10-14 years, and 15-18 years). At the discretion of the epidemiologist, a histogram displaying the total ED visits over the same time period was also provided if there were notable changes which may have impacted the overall percent of the ED visits related to suicide indicators. Finally, the results section concluded with a recommendation regarding whether the data indicated a need for immediate action to assist partners with decision-making for suicide prevention.
The eight school district partners with whom we met during our initial partnership meetings indicated that the use of these alert reports would be impactful to their prevention efforts due to their lack of real-time data. School district partners mentioned the use of the timely reports to initiate mental health promotion to students such as providing materials and messaging related to suicide help lines and other resources to encourage health-seeking behavior. This message campaign would include proactive communication to parents with additional resources for mental health promotion and suicide prevention. They indicated the usefulness of the stratification of the aggregate data to inform more targeted outreach based on geography, age group, sex, and race or ethnicity. This targeted approach would help them better identify which schools and what age group or other specific populations to direct mental health resources and crisis response support in their school districts. School district partners in these meetings also mentioned the ability to use these reports to enhance their youth suicide prevention curriculum and increase gatekeeper training for all school staff. Overall, all partners with whom we were able to connect provided feedback that they would have useful potential applications of these data alert reports.
Since the inception of this initiative, one partner at a participating school district developed a task force to specifically address mental health and suicide prevention in their district and expressed their interest in utilizing these data alerts to inform their prioritization of mental health resources, including staff time and outreach efforts. Additionally, one partner (from a district not yet participating in pilot reports) reached out to request suicide-related data for students in the specific county to present to their school board. Over a few short months, this data has been put into action by supporting the development of the task force and informing school board meetings and decision-making in our counties.
While the SyS Data Sharing for School-Based Suicide Prevention Initiative did not lend itself to outcome measures in the given timeframe, we were able to gather feedback on the pilot alert reports. In the pilot reporting period, we received two alerts, one for each district, and created two reports for these alerts to be shared as pilot reports with three mental health and crisis response team members of the two school districts. We met virtually to review the pilot reports for alerts detected in September in both partner school districts, resulting in two individual sessions for qualitative information-gathering. All three school district partners (representing two districts) communicated that the reports were helpful in providing situational awareness and simple to comprehend, even for lay folks. In addition to the stratification we provided by age and sex, all three partners from the two school districts requested further stratification by race and ethnicity and by geography, which were added to an updated alert report template. The race and ethnicity stratification table includes the percent of ED visits related to the suicide indicator among youth residents of the zip codes corresponding to the specified school district by race and ethnicity groups, with race and ethnicity categories separated as patients may identify as multiple race or ethnic groups. To provide more specified information by geography, choropleth maps were built in ESRI ArcMap (Version 10.8) to stratify the percent of ED visits related to the suicide indicator among youth residents of the zip codes corresponding to the specified school district by zip code. This will continue to be an iterative process and is a benefit of the SyS Data Sharing for School-Based Suicide Prevention Initiative that it can be tailored to meet the needs of each school district partner.
The long-term goals of the SyS SVP grant and the MCH and CFRT teams include reducing the number of suicides in Colorado. As part of the SyS SVP grant, we are tasked with weekly monitoring of suicide-related hospital trends regularly for the purpose of early detection and prevention of suicide. The SyS Data Sharing for School-Based Suicide Prevention Initiative is an important piece in ensuring that this long term goal is achieved. As we continue the SyS Data Sharing for School-Based Suicide Prevention Initiative, we will continue to monitor the long-term suicide-related hospital trends in these school districts as well as the timely alerts. We plan to capture the utilization, helpfulness, and additional qualitative feedback from our partners on a regular basis via a brief survey. We also plan to meet regularly with our school district partners, individually and in group settings, to collect information regarding the usefulness of this data, adjust our data communications as needed, and provide an opportunity for knowledge exchange. The sustainability of the SyS Data Sharing for School-Based Suicide Prevention Initiative relies upon the care and investment of these stakeholders and maintaining engagement with partners to ensure that these data products are helping them work towards these overarching shared long-term goals is pivotal.
Sources:
1. https://www.tchd.org/637/Syndromic-Surveillance-Newsletters-Repor