Epidemiological considerations point to a small handful of prevention strategies that have the potential for dramatically reducing suicide rates. Nearly all of those prevention approaches involve population-based strategies to either find an increased number of individuals at high risk for suicide or to reduce the prevalence of risk factors in members of a population that, as a whole, has a relatively low rate of suicide. Few of these approaches have been evaluated in rigorous trials. We argue that there are rigorous randomized trial designs that are both feasible and ethical and can be used to test both programmes and implementation strategies for population-based suicide prevention. We review existing suicide prevention trials and introduce two new randomized trial designs that are likely to achieve sufficient statistical power. The 'dynamic wait-listed design' randomizes across different time periods and is now being used to test a gatekeeper training programme in 32 schools. It could also be used to examine suicide prevention programmes in rural areas. The multi-trial follow-up study builds on the large number of successful population-based preventive interventions aimed at reducing known risk factors for suicide in youths to see whether these also cause a reduction in rates of completed suicide.
Context-Although there have been substantial advances in knowledge about drug prevention over the last decade, the majority of school-based drug prevention studies have been conducted in urban settings. There is little knowledge about the effectiveness of such programs when they are implemented in rural populations.Purpose-To examine the prevention effects of school-based drug prevention programs implemented in rural populations. Methods-Mixed model or two-level meta-analysis of trials based on school-based drug prevention programs that included rural populations. A total of 182 trials were coded for urbanicity of schools and 22 separate trials were selected for the analysis conducted in this paper. A total of 435 distinct analyses were examined from these 22 trials.Findings-We found a modest but consistent beneficial impact of drug prevention programs on later use as well as level of use. Regarding later drug use, the largest impact was on those who were not using at baseline and those exposed to an interactive program; the results were much larger for marijuana and other drugs compared to alcohol or tobacco, while inhalant use was less affected than other drug categories. Regarding level of use, the impact was greatest six months after the trial ended, with diminishing effects thereafter.Conclusions-Evidence exists for a small but systematic beneficial effect of drug prevention programs in rural settings. It is likely that these programs have produced a mild reduction in new use of substances but have had little impact on those already using substances.
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