Diverse Uses for Text Messaging to Engage Youth

1st Annual SPCNY Conference September 12, 2016

@tonypisani

Contributors (alphabetical)

Carolyn Anderson (UofR), C. Hendricks Brown (Northwestern), Carlos Gallo (Northwestern), Robert Filbin (Crisis Text Line); Madelyn Gould (Columbia), Kunali Gurditta (UofR), Mariya Petrova (U of Miami),Karen SchmeelkCone (UofR), Emily Thon (UofR), Peter Wyman (Uof R)

Mobile Phone Intervention to Reduce Youth Suicide in Rural Communities, NIMH K23MH101449 (PI: Pisani)

Effectiveness trial of youth suicide prevention delivered by teen peer leaders, NIMH R01MH091452 (PI: Wyman)

Teens4Teens: Above the Influence, Partnership at Drugfree.org, (PI: Wyman)

Youth Who Text a Crisis Line: Understanding Needs and Help-seeking, AFSP, (PI: Pisani)

Text4Strength

Text messaging in universal

school-based suicide prevention

program

Above the influence

Texting framework to support youth

implementers middle school substance use

prevention

Crisis Text Line

Text messaging to reduce

immediate risk

Wyman & Pisani (2015). Work in progress

Impact of Sources of Strength

• Increased healthy attitudes toward help-seeking, positive coping, school engagement (ES = 0.22 - 0.75)

• Increased connections to adults (ES = 0.49)• 4x more likely to refer peers to adults• Largest gains for the least connected peer leaders

• Increased help-seeking acceptability (ES = 0.58)• Increased perception that adults help suicidal peers (ES = 0.63)

(Largest gains for suicidal students)

Wyman et al, 2010, AJPH

Peer Leaders

School Population

Wyman & Pisani (2015). Work in progress

Healthy activities Would you rather Getting unstuck

Student Demo GroupsStudents demo and provide feedback on messages and

skill activities

Peer Leader WorkgroupPeer Leader write, record their success stories and

advice

Field TestersStudents receive and

interact with automated messages on their own

Aim 3: Randomized Trial

Aim 1: Development Aim 2: Field Test

Text4Strength

Total 9th Grade N = 132

(67 boys, 67 girls)

Parent Permission n = 40 30% of total

(18 boys, 22 girls)

School 1

Student Assent n = 36

(15 boys, 21 girls)

Cell Phone n = 28

(8 boys, 20 girls)

Field Test Sample= 42 (12 boys, 30 girls)

Total 9th Grade N = 43

(27 boys, 16 girls)

Parent Permission n = 18 42% of total

(7 boys, 10 girls)

School 2

Student Assent n = 17

(6 boys, 10 girls)

Cell Phone n = 14

(4 boys, 10 girls)

Percentage of boys and girls who replied to each of 28 sequences over 9 weeks of intervention

Perc

enta

ge o

f stu

dent

s wh

o re

plie

d

0%

13%

25%

38%

50%

63%

75%

88%

100%

SoS

Intro

Pos

Frie

nd

Men

tors

Fam

Sup

port

Heal

thy

Activ

ities

Gen

eros

itySp

iritu

ality

Med

ical

Acc

ess

Emot

Stra

tegi

es

Boys (n = 12)Girls (n = 30)

Total percentage of students who completed a sequence, if started (n = small!)

Perc

enta

ge o

f stu

dent

s wh

o re

plie

d

0%

13%

25%

38%

50%

63%

75%

88%

100%

SoS

Intro

Pos

Frie

nd

Men

tors

Fam

Sup

port

Heal

thy

Activ

ities

Gen

eros

itySp

iritu

ality

Med

ical

Acc

ess

Emot

Stra

tegi

es

Aver

age

perc

ent w

ho c

ompl

eted

seq

uenc

es

0%

20%

40%

60%

80%

100%

Maximum Number of Possible Responses

1 2 3 4 5 6 7 8

Average percent of students who completed sequences by length of sequence (n=41)

Num

ber o

f Stu

dent

s

0

5

10

15

20

25

30

35

40

Number of sequences

1 or

mor

e

3 or

mor

e

5 or

mor

e

7 or

mor

e

9 or

mor

e

11 o

r mor

e

13 o

r mor

e

15 o

r mor

e

17 o

r mor

e

19 o

r mor

e

21 o

r mor

e

23 o

r mor

e

25 o

r mor

e

27 o

r mor

e

Number of students who replied to at least N sequences

Strongly Disagree Disagree Neither

Agr/Dis Agree Strongly Agree

I enjoyed getting text messages from Sources of Strength. 0 0 5

(12%)29

(71%)7

(17%)I read messages even when I didn’t reply back. 0 0 1

(2%)22

(54%)18

(44%)It was fun to reply to messages and see what response I’d get. 0 1

(2%)8

(20%)25

(61%)7

(17%)I talked with my friends about texts I receive.

4 (10%)

13 (32%)

11 (27%)

12 (29%)

1 (2%)

I talked with my parents/family about texts I receive.

4 (10%)

9 (22%)

11 (27%)

12 (29%)

5 (12%)

I got bored with the messages after a while.

2 (5%)

19 (46%)

9 (22%)

2 (5%)

1 (2%)

I didn’t take the messages seriously.

12 (29%)

18 (44%)

9 (22%)

2 (5%) 0

I liked being able to share my own experiences and advice. 0 2

(5%)9

(22%)23

(56%)7

(17%)I felt comfortable texting personal things when asked. 0 7

(17%)10

(24%)20

(49%)4

(10%)

Appeal of Text4Strength Messages (n = 41)Strongly Disagree Disagree Neither

Agr/Dis Agree Strongly Agree

The texts gave good ideas for 9th graders to follow. 0 (%) 2

(5%)4

(10%)26

(65%)8

(20%)The texts helped me feel more confident to face challenges in high school.

2 (5%)

1 (2%)

8 (20%)

25 (61%)

4 (10%)

The texts made me more aware of adults I could talk to.

1 (2%)

2 (5%)

6 (15%)

28 (70%)

3 (7%)

The text helped me in my transition to high school.

2 (5%)

4 (10%)

11 (27%)

18 (44%)

5 (12%)

As a 9th grader, I could relate to the situations described in the texts.

1 (2%)

3 (7%)

5 (12%)

26 (65%)

5 (12%)

Next year, 9th graders at my school should get these texts. 0 0 4

(10%)20

(49%)16

(39%)

Strengths and Emotions

The texts helped me see my own strengths.

2 (5%)

1 (2%)

5 (12%)

26 (65%)

4 (10%)

The texts helped me understand my own feelings better.

2 (5%)

2 (5%)

7 (17%)

25 (61%)

4 (10%)

I learned new ways to handle emotionally upsetting situations

3 (7%)

3 (7%)

11 (27%)

18 (44%)

5 (12%)

Usefulness for 9th graders (n = 41)M

ean

1

1.8

2.6

3.4

4.2

5

Goo

d Id

eas

Mor

e Co

nfide

nt

Mor

e Aw

are

of A

dults

See

Stre

ngth

s

Unde

rsta

nd F

eelin

gs

Hand

le U

pset

Help

ed T

rans

ition

Coul

d Re

late

9th

grad

ers

shou

ld g

et

Fewest replies to texts (Bottom 1/3)Most replies to most texts (Top 1/3)

Equally “Useful” for Least and Most Engaged Students

Video Title Module Number (%) of Students Who Viewed Video

Average % of Video Viewed

By Those Who Watched

Finding My Place Fitting in 22 (55%) 92%Everyone's Really Cool Positive friends 12 (30%)‡ 85%You Can Love Food and Still Fit In Fitting in 9 (23%) 97%You Don't Really Have to Impress Anyone Fitting in 6 (15%) 60%Shakespeare Struggle Adult help 3 (8%)‡ 100%If I Knew Then What I Know Now Keep perspective 10 (24%) 78%Time Time Time Handling expectations 2 (5%)‡ 100%Do Things That Make You Happy Emotional strategies 11 (26%)‡ 80%Find People Who Make You Laugh, Happy* Positive friends 2 (5%)‡ 58%Get Your Emotions Out There Strong emotions 22 (55%) 74%Try New Things Positive activities 5 (12%) 90%Don't Be Afraid to Ask for Help Adult help 3 (7%) 98%Talk About It Strong emotions 9 (21%) 84%Getting Teachers’ Attention Puppet Show Adult help 6 (14%) 100%Bundled Up with Schoolwork and Activities Handling expectations 4 (10%)‡ 90%

Clicking and viewing peer leader videos about 9th grade pressures

‡ = video appears later in message sequence (not in opening line)

Strongly Disagree Disagree Neither

Agr/Dis Agree Strongly Agree

The videos I watched were interesting. 0 2 (7%)

6 (22%)

16 (59%)

3 (11%)

I could relate to the peer leaders’ stories 0 2 (7%)

6 (22%)

15 (56%) 3 (11%)

My friends and I handle challenges similar to those described… 0 2

(7%)9

(33%)14

(52%)2

(7%)

I recognized the students in the videos. 0 1 (4%)

3 (11%)

17 (63%)

6 (22%)

I preferred videos made by peer leaders who go to our school. 0 2

(7%)2

(7%)14

(52%)9

(33%)I thought peer leaders were being really honest in the videos.

0 1 (4%)

3 (11%)

16 (59%)

7 (26%)

I didn’t have time to watch videos. 5 (19%)

11 (41%)

6 (22%)

4 (15%)

1 (4%)

The program would be better without videos.

10 (37%)

9 (33%)

6 (22%)

2 (7%)

0

The videos gave me a good impression of Sources of Strength. 0 1

(4%)4

(15%)18

(67%)4

(15%)I liked hearing personal stories from upperclassmen.

0 1 (4%)

1 (4%)

22 (82%)

3 (11%)

Peer leaders didn’t talk about things I’m going through.

1 (4%)

6 (22%)

9 (33%)

9 (33%)

1 (4%)

Appeal of Peer Leader Videos (n = 27)

Summary of Preliminary Results• Enrollment consistent with many school-based

interventions, but lower than expected for intervention targeted as “grade-wide.”

• Most students found both text and video content helpful and relevant. They participated vigorously in offering ideas for improvement (http://t4s.co/post-suggestions)

• Most students interacted with less than a third of the sequences. Almost no differences by gender, distress, depression, preparedness for 9th grade, social isolation.

• Engagement with videos was low.

Student Demo GroupsStudents demo and provide feedback on messages and

skill activities

Peer Leader WorkgroupPeer Leader write, record their success stories and

advice

Field TestersStudents receive and

interact with automated messages on their own

Aim 3: Randomized Trial

Aim 1: Development Aim 2: Field Test

K23 Research Goals Refine and Expand• More personalized

• Funnier

• Fewer/no videos

• 9th-12th grade (school-wide)

• More peer leader involvement

• Mastery/completion, progression, narrative arc

Total School Population N = 1029

Parent Permission (~60%) n = 617

Student Assent (90%) n = 555

Cell Phone (90%) n = 500

Intervention n = 250

Active Control n = 250

Stratified by Grade, Sex; Randomized

Pilot RCTPre, Post, 3-months

• Target engagement: Proximal measures

• Help-seeking norms, attitudes, behavior (Pisani et al, 2011)

• Emotion self-regulation, Trusted Adults (Pisani et al, 2012)

• Secondary: Symptoms, Suicide ideation

• Depressive Symptoms, Anxiety Symptoms, Social Isolation

• Suicide ideation, Past 2 weeks (MFQ, Angold et al., 1996; Costello & Angold, 1988) Not

TrueSometimes True

Framework for supporting adolescent peer leaders: a pilot using text messaging in a school-based substance use

prevention program

Implementation Goal Message Themes Types of Text Messages to Communicate Themes

Enhancing peer leaders’ agency, knowledge of

mission, and team identity

Peer leaders are effective in reaching peers

You part of a bigger movement that is fun and powerful

Peer leaders make ATI relevant

Peer leaders’ expertise and opinions matter

Feedback about school-based activities

Links to photos of PLs being fun/silly; Examples of work from teams at other

schools; National ATI videos

Requests for feedback; Questions about messages, themes and

strategies will influence your friends

Supporting peer leaders’ connection to their ATI

mentor

Peer leaders’ ATI mentor cares about them, supports their group being effective, and is

dedicated to the causeEncouraging messages on behalf of

mentor

Reinforcing peer leaders’ personal application of program concepts in

their own lives

Peer leaders grow as a people, friends, leaders

ATI is personal to peer leaders & their friends

Many students rise above negative

Request to text back life examples of: True to You; Above negative

pressures; Positive Supports; The Facts about SA

Social norming polls/Q&A

Enhancing enthusiasm and preparation for

school-based prevention activities

Getting ready for meetings and activities makes them more fun and effective

Goal reminders, Preparatory videos, Meeting reminders

Implementation Goal Outgoing MessagesExample Student Replies

Enhancing peer leaders’ agency, knowledge of

mission, and team identity

Welcome and congrats for joining Above the Influence at {school}! You are part of a national teen

movement! :) abovetheinfluence.com

Don't forget–students and teachers at your school nominated you to be a Peer Leader because others

look up to you. You can define what's cool!

Congratulations on completing your first challenge! How do you think it went?

“Ok i am very excited, thank you :)”

“I thought it was better than I expected”

Supporting peer leaders’ connection to their ATI

mentor

Mr. Whalen said you did an amazing job last Friday! You put up 901 stickers! “Thank you, Mr. W :-)”

Reinforcing peer leaders’ personal application of program concepts in

their own lives

If a kid comes up to you in the hall and asks, "What is ATI?" You would say..

How does an adult help you stay true to you? A) I trust and can talk to thB) They're real w/me and encourage me C) I can be myself w/them D) Not

sure

“I would say ATI is a group that has kids help other kids with their problems. its when kids

take a stand so that other kids will rise above negative influences.”

“B and C”

Enhancing enthusiasm and preparation for

school-based prevention activities

Cafeteria challenge this week - spread the word, get 'em making "true to you" poster

Students at other ATI schools say they were nervous to present in front of their friends, but it paid off! How

do you feel about the upcoming presentations?

“Ok will do, thank you”

“I don't really feel nervous because I know most of the people in the classes”

“Scared”

Results: Student Replies• 35 of 41 (85%) of PLs replied to at least one text message.

• 30 of 41 replied to ≧3 messages

• Response rates varied from 22% to 56% across messages.

• Boys = Girls

• Hyperlinks: average 19 clicks/link (range 10-41)

• PL attendance: Little variability in two of three schools, but in the one school with variation, replies to texts correlated with better attendance (r = .774, p = .005).

Perception of Text Messaging:Peer Leader, Parent, and Staff Surveys

Agree/Strongly

Agree

Peer Leader

(41)

I read the messages even when I didn’t reply 95.1%The messages kept me focused on our mission 82.9%I would be interested in more… …links to videos 81.0% ...invitations to share advice and experiences anonymously 92.9% ...questions that get you thinking about how you handle pressures 95.1%

…quotes and stories from students facing the same stresses you face 90.5%

…short games like “choose your own adventure” related to ATI 87.8%

Parents(18)

Occasional text messages to Peer Leaders is a good way to support their mission and involvement 88.9%

Would be interested in receiving occasional text messages designed for parents of students involved in ATI 83.3%

School Staff(51)

Substance abuse prevention should incorporate internet use and text messaging 94.5%

I would be interested in receiving occasional text messages designed for those involved in ATI 59.5%

Group 1: School-based suicide prevention programming

Group 2: Support for program implementation

Group 3: Crisis text intervention

Discussion Groups