Feasibility of a Supportive Text Messaging Intervention in Northwest Alaska

Abstract

Suicide disproportionately impacts young Alaska Native people in the northwestern region of Alaska. As part of its efforts to address this challenge, Maniilaq Association developed a program to determine the feasibility of sending short text messages of caring and support. Process evaluation measures included the number of enrollees and the number of text messages sent each month. To determine participant satisfaction and seek recommendations for improvements, a short, online survey was disseminated to enrollees via text message in 2021 and 2022. Between January 2020 and September 2021, text messages were sent each month to about 100 participants, each with an accompanying image. Messages included “You are capable of amazing things” and “You are enough”. Twenty-five individuals completed the 2021 survey and 11 the 2022 survey; three quarters lived in Northwest Arctic. Respondents said the messages improved their mood and made them feel like they mattered a lot or a great deal. The intervention was well-received by participants, inspiring individuals to reach out to others and reach out for help for themselves. Recommendations for improvements included increasing culturally relevant and meaningful quotes and the frequency and consistency of messages. Due to concerns around confidentiality, it is unclear if the initiative reached those most at-risk for suicide. However, participants sharing the messages among the small population of the region may have facilitated a broader reach than would otherwise be expected.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41347-022-00293-z.

Suicide disproportionately impacts Alaska Native people in the northwestern region of Alaska, which is comprised of the Bering Strait Region and the Northwest Arctic Borough. Between 2014–2018, the age-adjusted suicide mortality rate among Alaska Native people in Northwest Arctic was 69.3 per 100,000, over twice as high as the rate among all Alaskans in 2019 (29.7 per 100,000) (Alaska Health Analytics & Vital Records Section, 2020) and over five times as high as the national rate of 13.6 in 2014–2018 (Alaska Native Tribal Health Consortium Epidemiology Center, 2021). Between 2010–2019, the age-adjusted suicide rate for youth ages 10–24 was 109.6 per 100,000 in Bering Strait and 114.7 per 100,000 in Northwest Arctic (Alaska Health Analytics & Vital Records Section, 2021).

To address these high rates of suicide among young Alaska Native people in northwestern Alaska, the Northwest Arctic Wellness Initiative (NAWI) was developed. Funded by a Substance Abuse and Mental Health Services Administration (SAMHSA) grant, the initiative was an intertribal youth suicide prevention cooperative agreement between several organizations in northwestern Alaska: Kawerak, Inc., Maniilaq Association (Maniilaq), the Bering Strait School District, the Northwest Arctic Borough School District, and Norton Sound Health Corporation (NSHC). From 2015 to 2020, the program served Alaska Native youth and young adults ages 10–24 in 27 villages in the region and supported comprehensive, culturally relevant, training and intervention strategies to create self-sufficient, sustainable, community-level suicide prevention, intervention and postvention for Alaska Native people. Evaluation services for NAWI were provided by the University of Alaska Anchorage (UAA).

As part of its postvention strategies, NAWI sought to develop and implement a program to enroll individuals to receive short, regularly scheduled messages of caring and support following their discharge from inpatient care services after a suicide attempt. This strategy was to be implemented and administered separately by both NSHC and Maniilaq.

The intervention built on findings that text-messaging based interventions are feasible and have the potential to reduce suicide and related behaviors. A meta-analytic review (Milner et al., 2015) of brief contact interventions, including telephone calls, postcards, and letters, found a reduction in repeated episodes of self-harm, suicide attempts, and suicide. The delivery of personalized unique contacts offering positive messages and reasserting the availability of services by letter (Motto & Bostrom, 2001) or phone call (Fleischmann et al., 2008) has been associated with significant decreases in subsequent suicide rates. Preliminary research has found text message-based interventions to be feasible (Berrouiguet et al., 2014; Kodama et al., 2016; Ligier et al., 2016). Randomized controlled trials of text message-based supportive messages have shown improvements in mood, symptoms, and health care system use for patients with depression and co-occurring substance abuse disorders during the intervention (Agyapong et al., 2012, 2013). Finally, a systematic review of seven studies examining text message-based interventions found that such programs hold promise for the support and management of people who experience mental health disorders (Watson et al., 2016).

However, several challenges prevented the implementation of the program as originally envisioned at both NSHC and Maniilaq: concerns regarding the maintenance of patient privacy and confidentiality in the sign-up process given the technology available; the ability of electronic health systems to accommodate the program; staff capacity to implement the program; the implementation of new electronic health systems at each of the organizations; and the arrival of the COVID-19 pandemic.

Due to these challenges, a modified version of the postvention was implemented only by Maniilaq, which manages health, social, and tribal services in a region with a population of about 8,000 people in the Northwest Arctic Borough. The strategy was designed primarily to test the feasibility of sending text messages and was implemented as an opt-in service without prerequisites, i.e., anyone could request to be enrolled. Those who opted in received supportive text messages about 2–4 times each month.

Methods

UAA worked closely with Maniilaq Behavioral Health Services (BHS) to develop and implement an evaluation plan for this revised strategy, including both process assessments collected from program staff as well as feedback from participants collected via an online survey. It was reviewed and approved by the University of Alaska Anchorage Institutional Review Board as not human subjects research (non-HSR).

Process Evaluation

The NAWI evaluation team met virtually with BHS about every other month from April 2020-September 2021 to collect process data. UAA entered collected data into an online form created for this purpose. Data elements included the number of text messages sent each month, when they were sent, their content, the number of new participants enrolled, the number who unenrolled, any technological issues encountered, how the program was marketed, and how the messages for that month were selected.

Recruitment

Recipient recruitment began in March 2019; anyone who wanted could opt-in. BHS promoted the program on the organization’s website and their public Facebook page. Recruitment also took place at community events through March 2020, at which point in-person recruitment was paused due to the COVID-19 pandemic. After March 2020, most marketing of the program took place through Facebook. The first texts were sent in November 2019. To better handle the volume of texts being disseminated, in January 2020 BHS began using Mozeo, a mobile marketing platform that allows businesses to send text messages to their customers who opt-in by providing their cell phone number. Mozeo complies with the Federal Communication Commission in requiring all purchasers of its services to obtain consent before any messages are sent. To receive the text messages, participants could request to be enrolled by BHS or auto-enrolled by texting “HOPE” to a specific number. Participants could opt-out at any time after they signed up. No demographic information was collected through Mozeo and only the BHS staff member responsible for sending the text messages had access to the BHS Mozeo account.

Participant Survey

An online survey of text message recipients was conducted using the Qualtrics platform. Participants were asked about their satisfaction with the program, suggestions to improve the program, impact of the program on their mental health and behavior, and demographic information. A link to the survey was disseminated using the same platform as the supportive messages on July 16, 2021, with reminder messages sent on July 22 and 28. Participants who completed the survey and provided their contact information were sent a $20 Amazon gift card by BHS as a thank you. This survey was repeated in December 2022 to affirm participant consent for survey data to be published in a peer-reviewed manuscript.

Findings

Process Evaluation

In January 2020 the program had 35 unique individual enrollees. Peak enrollment was 108 participants in October 2020; 102 were enrolled at the end of the evaluation in September 2021; 102 were enrolled when the repeat survey was conducted (Fig. 1). Unfortunately, data collected was inadequate to determine why people unenrolled from the program.

Fig. 1.

Number of enrolled text message recipients per month, January 2020-September 2021

The images and accompanying quotes used in the text messages were solicited from youth and other community members specifically for this project through Maniilaq’s Facebook page and community events. Examples of the messages include, “You are capable of amazing things”, “Know your worth”, and “You are enough” (Fig. 2). A total of 53 messages and images were selected by BHS based on a variety of factors, including the time of year and current events (e.g., during the early weeks of the pandemic, cheerful images were selected). Once all 53 original messages had been used at least once, they were recycled and sent again.

Fig. 2.

Example text message with a quote and an image of the local environment at sunrise

One BHS staff member was responsible for sending the selected text messages each month using the Mozeo service. Between January 2020 and September 2021, a cumulative total of 59 messages were sent to enrollees, averaging two messages per month (minimum 0, maximum 5). However, no messages were sent in April or May 2021 due to reduced staff capacity.

BHS sometimes occasionally received thank you messages back from the recipients. BHS also noticed that some recipients were posting on the public BHS Facebook page that receiving the messages inspired them. BHS staff reported that technical issues related to the sending and receiving of the text messages were rare.

Participant Survey

In July 2021 when the survey was intially disseminated, the program had approximately 102 enrolled participants. A total of 25 individuals completed the survey for an estimated 25% response rate. The majority of respondents (76%) lived in the Northwest Arctic region. The remaining 24% lived in other parts of Alaska or outside the state. This survey was repeated between December 2022 and February 2023 to affirm participant consent to have survey findings published; 11 people responded to this follow-up survey (10% response rate). While the results were similar between the 2021 and 2022 surveys, only the responses from the 2022 survey are described in detail here to ensure that only those with affirmed publication consent are reported.

Respondents were asked several satisfaction questions using a 5-point scale ranging from 1 (extremely dissatisfied) to 5 (extremely satisfied). Most reported being either extremely satisfied (46%) or somewhat satisfied (27%) with the text messages, while one person reported being extremely dissatisfied, but did not share the reasons for their dissatisfaction. Seventy-three percent (8 respondents) said that receiving the text messages improved their mood; 45% said they made them feel like they mattered a lot or a great deal. All the respondents said that the messages made them feel a least a little more connected to others. After receiving a message, 81% said they had reached out to someone else to see how they were doing; 18% said they had reached out for help for themselves after getting a message. Eighty-one percent somewhat agreed that the text messages made them feel like others would listen if they needed to talk.

When asked how often participants shared the text messages with others, five people (46%) said they never shared the messages while about half (18%) said they shared the messages “some of the time,” and 27% said always or most of the time. Family members (parents, siblings, cousins, aunts and uncles, and other family) were the most popular group to share the messages with, followed by friends, coworkers, other community members, and teachers.

Respondents’ qualitative comments included that they found the text messages to be inspirational or uplifting and that they enjoyed receiving pictures of local animals and plants and places they knew. In response to questions about what could be done to improve the program, survey participants recommended increasing the amount of culturally relevant and meaningful quotes, more consistency and frequency of the messages, and more local pictures. Almost two thirds of respondents said they would tell someone else to sign up for the messages.

Limitations

The adaptation of the texting initiative limited the ability of the intervention to target individuals most at risk of suicide. The direct impact of the intervention on suicidal ideation, self-harm, and other suicide-related behaviors is unknown. The 25% response rate of the participant survey means that the findings may not be generalizable to the entire participant population.

Conclusions

The texting initiative was well-received by participants, including inspiring individuals to reach out to others to see if they needed help and to reach out for help for themselves. Confidentiality concerns make it unclear whether the intervention succeeded in reaching the target demographic of those most at-risk for suicide. Based on the participant survey, the majority of survey respondents indicated that they shared the messages received. However, reach was limited among the 10–24-year-old demographic, which may indicate that either this intervention or the recruitment strategies used (primarily through BHS’s Facebook page after March 2020) were not well-suited to reach that demographic. To improve reach among this population, marketing of the service might be attempted through other social media platforms such as TikTok or Instagram, through schools, or after school programs. Additional marketing to people who may be at higher risk could be made through BHS’s outreach programs and clinic services. BHS intends to continue and expand the service as internal funding allows. Given the small population of the Northwest Arctic region, this may have facilitated a broader reach for this intervention than would otherwise be expected. Additional investigation of the population served by this intervention and additional marketing to the target population, may improve the effectiveness of this intervention.

Supplementary Information

Below is the link to the electronic supplementary material.

Funding

This initiative was part of the Northwest Arctic Wellness Initiative (NAWI), an intertribal Youth Suicide Prevention Cooperative Agreement between organizations in the Bering Strait Region and Northwest Arctic Borough of Alaska. NAWI was supported by the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services (SAMHSA) Administration Grant No. 6H79SM062905. These contents are solely the responsibility of the authors and do not necessarily represent the official views of the SAMHSA, the U.S. Department of Health and Human Services, or University of Alaska Anchorage Institute of Social and Economic Research.

Data Availability

Data may be made available with the permission of Maniilaq Association and/or Kawerak, Inc.

Declarations

Ethical Approval

This study was reviewed and approved by Kawerak, Inc. and Maniilaq Association. This manuscript was reviewed and approved for submission by Kawerak, Inc. and Maniilaq Association.

It was reviewed and approved by the University of Alaska Anchorage Institutional Review Board as not human subjects research (non-HSR). Before they participated, survey respondents were provided a description of the survey and its program improvement purpose. No identifying information was collected.

Conflict of Interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.