Implementation of a Suicide Prevention Gatekeeper Program in the University Setting

Title: Effectiveness of a Multicenter Suicide Prevention Gatekeeper Program for Students at Spanish Universities (GTK-UNI)

Background and Rationale:

Suicide is a leading cause of death among young adults worldwide, and university students represent a particularly vulnerable population due to psychosocial, academic, and transitional stressors. Despite the growing recognition of the importance of suicide prevention, few evidence-based interventions have been adapted for university environments in Spain. Gatekeeper Training (GKT) programs are short interventions designed to equip non-specialists with the ability to recognize warning signs, intervene appropriately, and refer at-risk individuals to professional support. This project, titled GTK-UNI, aims to develop, implement, and rigorously evaluate the effectiveness of a Gatekeeper Training program adapted to Spanish university settings.

Study Objectives:

The main objective of this multicenter randomized controlled trial (RCT) is to evaluate the effectiveness of a suicide prevention Gatekeeper program delivered to university students. The program will be tested both in online and face-to-face formats to determine its utility, scalability, and long-term impact. Specific aims include:

Designing a structured and culturally relevant GKT program for university students in Spain.

Validating two measurement tools in Spanish: the Willingness to Intervene Against Suicide Enhanced Questionnaire (WISE) and the ACT as Gatekeeper questionnaire.

Implementing the program in both in-person and online formats to ensure accessibility.

Measuring the impact of the training on knowledge, attitudes, perceived control, and actual gatekeeper behaviors, with gender-stratified analyses.

Evaluating participants' adherence to and satisfaction with the program, identifying gender-related barriers and facilitators to participation.

Collecting qualitative data through focus groups to explore how gender norms influence program engagement and effectiveness.

Disseminating results to support gender-sensitive suicide prevention strategies in educational and mental health policy.

Contributing to translational research by developing a validated guide for university-level suicide prevention planning.

Methods:

This is a multicenter, two-arm, randomized controlled trial with a waitlist control group. Participants are university students (age ≥18) from multiple Spanish universities, recruited via university mailing lists, social media, student associations, and institutional partnerships. Recruitment materials clarify that the training is a suicide prevention initiative and outline the voluntary nature of participation.

Randomization and Conditions:

After providing informed consent, participants are randomly assigned to one of two groups:

Intervention group (GTK-IG): Receives the Gatekeeper Training immediately, either in online or face-to-face format, depending on their preference.

Delayed Intervention Group (GTK-DG): which will be a waitlist control during the first phase of the study and will receive the interventions after T2 (2-3 months later).

Training Format and Content:

The GTK-UNI program consists of 6 modules delivered in two 3-hour sessions over two weeks. Modules include:

Introduction to suicidal behavior and epidemiology

Recognition of warning signs and risk/protective factors

Crisis intervention and suicide first aid strategies

Safety planning and community resources

Ethics and self-care for gatekeepers

Practical evaluation and case simulation

Evaluation Timeline:

T0 (Baseline): Online survey before intervention

T1 (Post-intervention): Immediately after last session (two weeks after T0)

T2 (Follow-up): To be conducted 2 months after T1, with a booster session and focus group for GTK-GE participants scheduled approximately 2.5 months after T0.

T3 (Follow up 2): 9-12-month after T1.

After each session: Assessments will be also administered to monitor progressive skill acquisition.

Control group receives the training after T2 (approximately 2.5-3 months after T0)

Instruments:

Primary outcome measures include:

WISE Questionnaire (Aldrich \& Cerel, 2024): Measures attitudes, norms, perceived control, and intention to intervene.

ACT as Gatekeeper (Nozawa et al., 2020): Evaluates actual gatekeeper behaviors.

Secondary outcomes:

LOSS-SF (Calear et al., 2022): Assesses suicide literacy. SOSS-SF (Batterham et al., 2012): Measures stigma toward suicide. PHQ-9 (Kroenke et al., 2001): Assesses depressive symptoms. Additional variables include emotional burden, satisfaction, gender, and open-ended responses on program perception.

• Change in Suicide Literacy Score Using LOSS-SF from Baseline to 2-Month Follow-Up [Time frame: From baseline (T0) to T1 (2 weeks after T0), with a 2-3month follow-up at T2 (approximately 2.5 months after T0) and a follow-up at 9-12 months from T1 (T3).]
• Change in Stigma Toward Suicide Score Using SOSS-SF from Baseline to 2-Month Follow-Up [Time frame: From baseline (T0) to T1 (2 weeks after T0), with a 2-3month follow-up at T2 (approximately 2.5 months after T0) and a follow-up at 9-12 months from T1 (T3)]
• Change in Depressive Symptoms Using PHQ-9 from Baseline to 2-Month Follow-Up [Time frame: From baseline (T0) to T1 (2 weeks after T0), with a 2-3month follow-up at T2 (approximately 2.5 months after T0) and a follow-up at 9-12 months from T1 (T3)]
• Self-Reported Emotional Burden After Completing Gatekeeper Training [Time frame: From baseline (T0) to T1 (2 weeks after T0), with a 2-3month follow-up at T2 (approximately 2.5 months after T0) and a follow-up at 9-12 months from T1 (T3)]
• Participant Satisfaction and Perceived Preparedness After Gatekeeper Training [Time frame: Immediately after the training (T1): two weeks after T0.]
• Suicidal behavior (self and others) [Time frame: From baseline (T0) to T1 (2 weeks after T0), with a 2-3month follow-up at T2 (approximately 2.5 months after T0) and a follow-up at 9-12 months from T1 (T3)]
• Intersession skill monitoring [Time frame: After each training session.]