Supporting Statement

Pretesting Suicide Prevention Messages and Materials with Veterans

Supporting Statement

1. Justification

1. Circumstances of Information Collection

The Center for Mental Health Services (CMHS) of the Substance Abuse and Mental Health Services Administration (SAMHSA) is requesting OMB approval for seven new instruments to be used to pretest suicide prevention messages and materials with veterans: 1) Moderator’s Guide: Suicide Prevention Messages and Materials for Veterans (Attachment 1);

2) Privacy Protection Agreement for Focus Group Participant Recruiters (Attachment 2);

3) Privacy Protection Agreement for Focus Group Moderators, Note Takers, and Observers (Attachment 3); 4) Privacy Protection Agreement for Transcribers (Attachment 4); 5) Informed Consent Form (Attachment 5); 6) Recruitment Flyer (Attachment 6); and 7) Participant Screener and Recruitment Script (Attachment 7). The specific messages and materials to be pretested are included in Attachment 8.

CMHS is responsible for the National Suicide Prevention Lifeline (Lifeline), a network of 135 crisis centers in 47 States that receives calls from the national, toll-free suicide prevention number, 1-800-273-TALK. Calls to the Lifeline are automatically routed to the closest crisis center based on the caller’s area code. Local crisis centers then link callers to emergency, mental health, and social service resources closest to the caller’s location. The Lifeline is administered through a grant from SAMHSA to Link2Health Solutions, a subsidiary of the Mental Health Association of New York City.

In order to meet the special needs of veterans, SAMHSA, the U.S. Department of Veterans Affairs (VA), and the Lifeline launched the Veterans Suicide Prevention Hotline in 2007. The hotline provides national, around-the-clock access to crisis counseling services for all veterans and their families in emotional distress or suicidal crisis. Veterans seeking help, family members, or other loved ones concerned about a veteran in emotional distress, can access immediate help by calling 1-800-273-TALK and pressing “1” to be connected to a specialized call center operated by the VA and staffed by mental health professionals.

Effective messages and materials are essential to increasing the number of veterans who call the hotline. The messages and materials to be pretested promote the hotline and encourage veterans to call 1-800-273-TALK and press “1”.

2. Purpose and Use of Information

The purpose for the proposed focus groups is to increase the effectiveness of promotional efforts for the VA Suicide Prevention Hotline among veterans. The objectives are to ensure that the messages and visuals are clear and effective and that they motivate veterans to call the hotline.

CMHS proposes conducting one set of mini-focus groups with veterans from all branches of military services—with an emphasis on those from the Army and those who served, or are serving, in the National Guard—who have combat experience in Iraq or Afghanistan during the current conflicts, and are between the ages of 20 to 29.

Mini-focus groups have some distinct advantages over standard-sized focus groups:

• Mini-focus groups of 4 to 6 are more cost-effective than a standard-sized focus group of 8 to 10 participants.

• Smaller group size may enable participants to feel more comfortable discussing sensitive and complex topics, such as suicide or emotional distress.

• Smaller group size will allow participants time to provide more in-depth information. This can be important for sensitive topics—if a participant begins to share his or her experience, the moderator has the latitude to allow them to talk, rather than moving on in the interest of time, and/or hearing feedback from everyone in the group.

The discussion will focus on specific language used in the materials, as well as the appropriateness and effectiveness of visual elements, such as color and images, to move the audience to action. A Moderator’s Guide will be used to structure and facilitate the discussion in each group. The guide for these focus groups is included in Attachment 1.

Notes and audio recordings from the focus groups will be analyzed for message comprehension and reactions to visual elements. The analysis will highlight common themes or concerns that emerge from the focus groups as indicators of how materials and messages resonate with the intended audience. The results will be used to refine suicide prevention messages and materials for veterans.

3. Use of Information Technology

The information will be gathered in person by an experienced focus group moderator meeting with six groups of 5 participants each. Collecting the information in written form, through the mail or electronically, would not be effective in obtaining the kind of information required. The nuances of the information requested require face-to-face discussion and fully understanding them depends on probes from an experienced moderator. Open-ended questions will be used to elicit opinions and reactions. To respond to the questions in the Moderator’s Guide in writing would require long, essay-type answers and be more time-consuming than in-person mini focus groups.

4. Efforts to Identify Duplication

The information needed is specific to the messages and materials to promote the VA Suicide Prevention Hotline and is not collected anywhere else.

5. Involvement of Small Entities

This project will not have a significant impact on small businesses or entities.

6. Consequences if Information Collected Less Frequently

Each respondent will be asked to respond only once.

7. Consultation Outside the Agency

The instruments have been submitted to three experts for review:

John A. Hermann

IRB Chair

Macro International, Inc.

11785 Beltsville Drive, Suite 300

Calverton, MD 20705

Tel: (301) 572-0340

Email: [email protected]

Janet Kemp RN, Ph.D.

VA National Suicide Prevention Coordinator

Associate Director Education and Training

VISN 2 Center of Excellence at Canandaigua

400 Fort Hill Ave.

Canandaigua, NY 14424

Tel: (585) 393-7939

Email: [email protected]

Melodee Mercer

Department of Veterans Affairs

Philadelphia VA Regional Office

5000 Wissahickon Avenue
Philadelphia, PA 19144-4867

Tel: (215) 842-2000 Ext. 4267

Email: [email protected]

8. Payment to Respondents

Respondents will receive $50 for the session to ensure sufficient numbers participate in the focus groups. The population being recruited for these focus groups is difficult to reach.

9. Assurance of Confidentiality

CMHS will require that the following focus group participants read and sign protection agreements:

• Participant recruiters (Attachment 2);

• Moderators, note takers, and observers, including VA Suicide Prevention Coordinators (Attachment 3); and

• Transcribers (Attachment 4).

Veterans who agree to participate will be asked to sign an Informed Consent Form (Attachment 5) prior to the focus group. Focus group participants will have time to review the form and ask questions prior to the start of the discussion.

To further ensure participant privacy, transcripts will remove all references to each participant’s identity beyond his or her first name and all focus group tapes, notes, and transcripts will be destroyed when the project is completed.

The Moderator’s Guide, Privacy Protection Agreements, Informed Consent, Participant Screener and Recruitment Script, and Recruitment Flyer have been reviewed and approved by the corporate Institutional Review Board of Macro International, Inc. (Macro). The IRB review and approval process ensures that issues relating to human subjects are addressed quickly and efficiently and that CMHS adheres to the highest possible standards of evaluation. A copy of the IRB findings and approval can be found in Attachment 9.

10. Questions of a Sensitive Nature

Depending on a person’s background and experiences, questions involving suicide always have the potential to be sensitive and to raise emotional issues and memories. Because of the nature of the product mentioned in our messages and materials—a suicide prevention hotline—our questions must include the issue of suicide.

Given the sensitive nature of these questions, a VA Suicide Prevention Coordinator (SPC), a licensed mental health therapist who works with veterans at risk for suicide, will be available during and after each group and in every location to ensure that, if needed, he or she can privately and confidentially assist focus group participants who may be in distress. Participants will be told that they can speak privately to the SPC at any time during or after the group, no questions asked, and still receive their incentive. Depending on his/her clinical assessment of the participant’s mental health, the SPC can also offer therapeutic services to the participant at a later date in a VA setting.

Print materials on suicide prevention, including the telephone number for the 24-hour suicide prevention toll-free hotline, will also be available for the participants to take away after each group.

11. Estimates of Annualized Hour Burden

It is estimated that 40 respondents will have to be screened in order to recruit 30 focus group participants. Each screening will take approximately 12 minutes. The estimated response burden for the screening process is 8 hours.

The focus groups will have an average of 5 participants each. Six focus groups will be conducted for a total of 30 participants. The focus groups will take 2 hours each for a total burden of 60 hours.

The informed consent will take approximately 6 minutes to complete for a total burden of 3 hours.

Form Name	No. of Respondents	Responses per Respondent	Total Responses	Hours per Response	Total Hour Burden	Hourly Wage Cost	Total Hour Cost
Participant Screener and Recruitment Script	40	1	40	.20	8	$20	$160
Moderator’s Guide: Suicide Prevention Materials for Veterans	30 (6 groups x 5 participants per group)	1	30	2	60	$20	$1,200
Informed Consent	30 (6 groups x 5 participants per group)	1	30	.10	3	$20	$60
SUB-TOTAL	100	--	100	--	71	--	$1,420

It is estimated that privacy protection agreements will take 3 minutes to complete for a total burden of .40 hours or 24 minutes.

Form Name	No. of Respondents	Responses per Respondent	Total Responses	Hours per Response	Total Hour Burden	Hourly Wage Cost	Total Hour Cost
Privacy Protection Agreement for Focus Group Recruiter	1	1	1	.05	.05	$20	$1
Privacy Protection Agreement for Moderators, Note Takers, Suicide Prevention Coordinators, and Observers	6 (1 moderator, 1 note taker, 3 Suicide Prevention Coordinators, 1 transcriber)	1	6	.05	.30	$20	$6
Privacy Protection Agreements for Transcribers	1	1	1	.05	.05	$20	$1
SUB-TOTAL	8	--	8	--	.40	--	$8
TOTAL	108	--	108	--	71.40	--	$1,428

The hourly wage cost is based on the U.S. Department of Labor’s “May 2007 National Occupational Employment and Wage Estimates” which lists the mean hourly wage for all occupations as $19.56. See: http://www.bls.gov/oes/current/oes_nat.htm#b00-0000

12. Estimates of Annualized Cost Burden to Respondents

There are no costs to respondents associated with either capital and startup efforts or operation and maintenance of services for this project.

13. Estimates of Annualized Cost to the Government

The cost to CMHS of the contract task to collect this information is $66,000.

Additionally there is an estimated cost of $1,722 for 40 hours for the Government Project Officer (GS-13, Step 2) to coordinate with the contractor.

14. Changes in Burden

This is a new project.

15. Time Schedule

It is anticipated that participant recruitment will begin 2 to 3 weeks following OMB approval and that it will take approximately 4 weeks to recruit the full complement of participants in each site. Focus groups will be conducted 3 to 6 weeks after recruitment is complete. The analysis and report will be completed 4 weeks after the final focus group is conducted.

2. Statistical Methods

1. Respondent Universe and Sampling Methods

Although most veterans of Iraq and Afghanistan are men who served in the Army, CMHS will recruit combat veterans from all branches of services. It is expected and desired, however, that most participants will be Army veterans. Since those who served, or are serving, in the National Guard may be at higher risk of death by suicide¹, it is also essential to obtain representation from this population. It is, likewise, important to have representation from both sexes, while recognizing that the majority of combat veterans are men, as well as to ensure appropriately diverse racial and ethnic backgrounds within the context of the recruitment areas.

The VA requested that SAMHSA recruit focus groups in the following locations for a variety of reasons, including its desire to serve more veterans in rural areas, the areas’ population base, proximity to Army military bases, and size of their Army National Guard units:

• San Antonio, Texas

• Lenoir, North Carolina

• Helena, Montana

2. Information Collection Procedures

Identification and Contacting of Participants

SPCs will work through National Guard units and use their community contacts to proactively identify participants. When a potential participant is identified, the SPC will give the person a Recruitment Flyer (Attachment 6) that lists the focus group dates, times, and location. The flyer also contains a toll-free telephone number interested individuals can call for more information and to enroll in a focus group without incurring long-distance charges.

SPCs will also place flyers in community settings where potential participants are likely to be present, including community colleges, universities, VA hospitals, Veterans of Foreign Wars and American Legion halls, community centers, grocery stores, and laundromats.

Upon being contacted by potential participants, an experienced focus group recruiter will use the Participant Screener and Recruitment Script (Attachment 7) to identify and enroll eligible participants who fit the following profile:

• Veterans from all branches of military services—with an emphasis on those from the Army and those who served, or are serving, in the National Guard.

• Veterans who have been deployed in Iraq or Afghanistan during the current conflicts.

• Veterans between the ages of 20 to 29.

The recruiter will aim to meet the following segmentation, which is based on Armed Forces² demographics and that of focus group communities³:

Demographic Characteristics		Estimated Percentage of Total Participants	Estimated Number of Total Participants
Sex
	Men	85	26
	Women	15	4
Race/Ethnicity
	American Indian or Alaska Native	3	1
	Asian	3	1
	Black or African American	13	4
	Native Hawaiian or Other Pacific Islander*	--	--
	White	71	21
	Hispanic or Latino	10	3
Armed Forces Branch
	Army	30	9
	Army National Guard	30	9
	Marine Corps	7	2
	Navy	14	4
	Air Force	14	4
	Air National Guard	3	1
	Coast Guard	2	1
Enrolled in VA Services
	Yes	60	18
	No	40	12

*CMHS does not expect to recruit Native Hawaiians or Other Pacific Islanders given the small percentage of representation of these populations within the Armed Forces and in the communities where focus groups will be conducted.

The segmentation above represents a best case scenario for recruitment of focus group participants. Since the groups address very sensitive issues and two of the three communities are located in rural areas, it might not be possible to fully meet this breakdown of demographic characteristics. Some deviation is anticipated in order to meet the focus group sample size.

As with most focus groups, participant attrition is expected. CMHS will enroll 6 to 8 people for each group with the expectation that an average of 5 will actually participate. Should there be no attrition, all those enrolled will be allowed to participate in the group.

Conducting Focus Groups

Two focus groups will be conducted in each location. Focus groups will be led by an experienced moderator with knowledge of social marketing, veterans, and suicide prevention. The protocol is outlined in the Moderator’s Guide (Attachment 1).

Content Capture

A CMHS contractor will take notes during each focus group using a secure laptop that can only be accessed through a unique login and password. The notes will capture the following information:

• Participant quotes;

• Non-verbal cues (such as laughter, nodding, and discomfort); and

• Follow-up questions.

High-quality audio tape equipment will be used to ensure an accurate recording of the discussion. All audio tapes will be accurately labeled with date, time, and location and they will be collected by the moderator at the conclusion of each focus group. The audio tapes will be in the moderator’s possession or in a secure location at all times until they are sent to a transcription service firm.

Once electronic transcripts are produced, they will be stripped by the contractor of all references to participant identities beyond first names. Audio tapes will be destroyed when transcripts are obtained and the project is completed.

3. Methods to Maximize Response Rates

To maximize response rates, CMHS is working closely with VA SPCs and National Guard representatives to identify participants. Each SPC has been briefed by a CMHS social marketing contractor on the objectives, number of participants, setting, and logistics for the focus groups.

If needed, a professional recruitment firm will also be contracted to meet the target sample size. Professional agencies are able to recruit participants very efficiently and can ensure the appropriate number of participants is available for the focus groups. Recruitment firms have been identified in each community and have been briefed on the requirements of the focus groups. The determination to contract these firms will be made two weeks after each SPC begins their recruitment efforts. If fewer than six eligible participants are identified, screened, and recruited in each community during this two-week time period, then the professional recruitment firm will supplement the work of the SPC.

To further maximize response rates, focus groups will be held after working hours and/or on weekends in settings that allow participants to feel comfortable and to articulate their views and feelings. CMHS is working closely with the VA and the National Guard to identify settings that are accessible and familiar (e.g., public libraries and community college meeting rooms) to potential participants.

4. Tests of Procedures

The Moderator’s Guide for these focus groups is based on instruments used to pretest other suicide prevention messages and materials. Specifically, in 2004, CMHS worked with The Gallup Organization and Macro to conduct focus groups to test potential brand concepts for what would, eventually, become the National Suicide Prevention Lifeline. The Moderator’s Guide for those focus groups yielded questions about hotline beliefs and barriers and brand components such as designs, names, and telephone numbers.

In 2006, Macro conducted eight mini focus groups for the Georgia Crisis Access Line to test the positioning and key messages of this statewide hotline that provides immediate access to local mental health services, including suicide prevention. Questions captured from the moderator’s guide for these focus groups include those related to help-seeking behaviors during a crisis, both for the consumer and their friends; motivation for calling a hotline; and channels and materials to deliver key messages.

Questions from both sets of focus groups delivered results that helped guide successful marketing campaigns, including launch of the Lifeline.

5. Statistical Consultants

Eileen Zeller, SAMHSA/CMHS/ DPTSSP, 240-276-1863

Mary Yakaitis, The Gallup Organization, 202-715-3096

List of Attachments

Attachment 1: Moderator’s Guide: Suicide Prevention Messages and Materials for Veterans

Attachment 2: Privacy Protection Agreement for Focus Group Participant Recruiters

Attachment 3: Privacy Protection Agreement for Focus Group Moderators, Note Takers, and

Observers

Attachment 4: Privacy Protection Agreement for Transcribers

Attachment 5: Informed Consent Form

Attachment 6: Recruitment Flyer

Attachment 7: Participant Screener and Recruitment Script

Attachment 8: Messages and Materials to be Pretested

• “Know the Warning Signs of Suicide” Brochure (Exterior)

• “Know the Warning Signs of Suicide” Brochure (Interior)

• “It Takes the Courage and Strength of a Warrior” Poster 1

• “It Takes the Courage and Strength of a Warrior” Poster 2

• Veterans Suicide Prevention Hotline Logo 1

• Veterans Suicide Prevention Hotline Logo 2

• Television Public Service Announcement Transcription

Attachment 9: IRB Approval

1 Suicide seen as major threat to National Guard Soldiers [http://www.ngb.army.mil/news/archives/2007/08/082007-Suicide_NG.aspx]

2 Profile of the Military Community: DoD 2006 Demographics [https://cs.mhf.dod.mil/content/dav/mhf/QOL-Library/Project%20Documents/MilitaryHOMEFRONT/Reports/2006%20Demographics.pdf]

3 U.S. Census Bureau [http://www.census.gov/]

11