Using Information and Communication Technologies to Prevent Suicide Among Secondary School Students in Two Regions of Chile: a Randomized Controlled Trial
Phase: NA
Conditions: Suicide, Adolescent Behavior
Sponsor: University of Chile

 

Approval Document Human 
Subjects Research Project 
 
 
With a date of November 30th, 2016, the Ethical Committee of Human Subjects 
Research of the Faculty of Medicine, Universidad de Chile, integrated by the 
following members: 
 
Dr. Manuel Oyarzún G., Pulmonologist, President 
Prof. Gina Raineri B., Lawyer and Nurse - Matron, Master in Bioethics, 
Secretary Dr. Hugo Amigo C., Ph.D., Public Health Specialist 
Dr. Lucia Cifuentes O., Physician Geneticist, 
Dr. María Angela Delucchi Bicocchi, Pediatric 
Nephrologist Dr. Miguel O’Ryan, Infectious Disease 
Physician 
Mrs. Claudia Marshall F., Educator, Community 
representative Dr. Gricel Orellana, Neuropsychiatrist 
Prof. Julieta González B., Cellular Biologist 
 
Has revised the research project, entitled: DEVELOPMENT AND EVALUATION 
OF AN INTERVENTION MODEL BASED ON INFORMATION AND 
COMMUNICATIONS TECHNOLOGY (ICT), TO REDUCE THE RISK OF 
ADOLESCENT SUICIDE IN EDUCATIONAL ESTABLISHMENTS OF THE 
METROPOLITAN REGION AND SIXTH REGION, and whose 
responsible researcher is Dr. Ruben Alvarado Muñoz, who works in the Public 
Health School, Faculty of Medicine, Universidad de Chile. 
 
The Committee revised the following study documents: 
 
 Complete research project 
 CV of the principal investigator and the co-investigators 
 Letter of acceptance from the authorities of the institutions where the 
study will be conducted 
 Informed consent 
 Letter from researcher, which expresses his commitment to communicate 
the results of the study once it is finalized. 
 
The project and documents indicated in the preceding paragraph have been 
analyzed in light of the tenets of the Helsinki Declaration, of the International 
Ethical Guidelines for Biomedical Research in Human Subjects CIOMS 2002, and 
Good Clinical Practice Guidelines of ICH in 1996. 
 
On the basis of this information, the Ethical Committee of Human Subjects 
Research of the Faculty of Medicine of the Universidad de Chile has declared the 
following with regard to the indicated aspects of the project: 

a) Character of the studied population: captive, therapeutic 
b) Utility of the project: Useful 
c) Risks and Benefits: Scarce 
d) Participant protection: Yes 
e) Timely notification of adverse events: Yes 
f) The principal investigator has expressed his commitment to give 
the committee the study results at the end of the project: Yes 
 
Therefore, the Committee esteems that the proposed study has been well justified 
and does not signify significant physical, psychic, and social risk for the involved 
subjects. 
 
In virtue of the aforementioned considerations, the Committee grants the 
ethical approval to carry out the proposed study, in line with the specifications 
of the protocol. 
 
Santiago, November 30, 2016. 
 
 
 
 
  
 
Executive Secretary CEISH 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
Protocol title: Development and evaluation of an intervention model based on information and communications 
technology (ICT), to reduce the risk of adolescent suicide in educational establishments of the metropolitan 
region and sixth region. 
 
Date: April 19th, 2018 
 
 
 

INTRODUCTION 
 
The World Health Organization reports that over 800,000 people die by suicide each year, 
and life-threatening behaviors are 10 to 20 times more frequent than completed suicides 
(1). Suicide prevalence varies throughout the lifespan, and for individuals between 15 and 
29 years of age, it is the second leading cause of death globally, resulting in a massive 
burden for individuals, families, and communities at large. While statistics differ between 
countries and regions, it is estimated that 75% of all suicides occur in low-and-middle 
income countries (LMICs) (1). 
 
 
Several high-income countries (HICs) have developed and implemented suicide 
prevention strategies. The effectiveness of such approaches, while promising, has yet to 
be fully established, and further research is needed (2). In LMICs, the knowledge gap is 
even wider – only a few interventions have been tested so far (3), in spite of the increasing 
prevalence rates recently reported (4). 
 
 
In Latin America in particular, suicide rates have been rising over the past two decades 
(5), principally among adolescents and older adults, which poses a challenging and urgent 
problem for health services. Chile, for its part, has one of the highest rates of adolescent 
suicide worldwide (6), and addressing suicide has been named one of the principal health 
goals of the decade (7). Although a National Plan on Adolescent Suicide is already in 
place, initiatives specifically tailored to this population have been scarcely implemented. 
The Plan, however, does highlight the importance of developing programs to prevent 
suicide through the promotion of self-esteem and self-efficacy, the strengthening of familial 
and community ties, and the construction of support networks among adolescents (8). 

In this paper, we describe a cluster randomized controlled trial (RCT) of an intervention to 
prevent adolescent suicide, through a web-based platform and mobile application that will 
cultivate a community directed towards a goal of mutual support, in order to foster mental 
health protective factors and strengthen collaborative relationships among high school 
students, in two regions of Chile. 
 
 
Past interventions based on information and communications technologies to 
reduce suicide 
Some have noted that information and communications technology (ICT)-based 
interventions – which use technologies such as desktop and laptop computers, hardware 
and software, mobile applications, and internet-based programs – may offer several 
advantages to address suicide among adolescent populations by 1) promoting an 
accessible, engaging, and collaborative learning and exchange environment for 
adolescents; 2) fostering creativity, self-expression, and collective generation of content; 
and 3) strengthening self-identity and the development of social connections, through the 
constitution of social networks and peer support groups (9, 10). 
 
 
ICT interventions specifically designed to prevent suicide or address associated factors, 
such as depression, bullying, anxiety disorders, stress, and wellbeing, in adolescents have 
been piloted in High Income Countries (HICs), showing promising results in coverage, 
access, and cost-benefit effectiveness (11). Most of these programs, however, have only 
been tested in non-controlled trials, thus making it difficult to recommend their 
implementation on a larger scale or as a regular provision of public services (12). 
 
 
In this regard, Lai et al. (12) carried out a systematic review of all internet-based 
interventions that have sought to prevent suicide or associated factors with a focus on 

analyzing the effectiveness of and what are possible barriers to these programs. Of the 
thirteen studies that met inclusion criteria, only three were RCTs. The review also notes 
that it was not possible to determine an overall effect size, due to a lack of homogeneity 
with respect to the population, study design, evaluation methods, and intervention 
characteristics. 
 
 
Of particular relevance is a large RCT conducted in seven European countries which 
evaluated a program, entitled “Supreme Project”, that was designed to promote protective 
factors in secondary school students through a series of online resources such as fact 
sheets, chats, forums, and games (13). Participants in the intervention group reported 
using the web platform almost every day and had a positive impression of its content and 
format. Main findings of the trial showed that the intervention group had decreased suicide 
risk and improved self-esteem (14). Nevertheless, differences between the control and 
intervention groups were not significant at follow-up. 
 
 
Additional qualitative findings from the Supreme Project (14) indicate that the following 
practices should be considered in future suicide prevention programs: 1) the incorporation 
of adolescents as “peers”; 2) a gender-specific approach to tailor and adapt contents; 3) 
culturally-sensitive adaptations for each strategy included in the program; 4) ongoing 
evaluations; and 5) the assessment of outcomes such as acceptability, satisfaction, and 
adoption, to inform the feasibility of implementing the intervention. These practices have 
strongly influenced our intervention proposal as detailed below. 
 
 
Using ICT-based interventions to prevent suicide in Chile and Latin America 
 
It is estimated that only 45% of adolescents with suicidal risk in Chile have access to in- 
person treatment with a mental health professional (15). This gap is partially due to the 

limited availability of specialized mental health services for adolescents, lack of information 
about existing services, as well as adolescents’ resistance to seek professional help, due 
to fear of being stigmatized by their peers, community or even their parents (16, 17, 18). It 
has been suggested that web-based interventions and/or mobile applications could be 
particularly suitable for adolescents, to overcome the aforementioned barriers to treatment, 
since ICTs provide easy access to valuable resources and reduce possible stigma 
associated with help-seeking and mental distress (19). 
 
 
ICT-based interventions have special potential to be implemented in Chile (and elsewhere 
in Latin America), since the vast majority of the population has internet access and use of 
electronic devices - laptops, smartphones, tablets, etc. – is common across all social strata 
(20). Among adolescents in Chile, Internet use is even more intensive (90% connect at 
least once a day) (21). Adolescents, moreover, are not afraid to interact with others using 
new technologies in comparison to adults and older adults. Thus, leveraging technological 
solutions provides a strategic opportunity to reach young populations with an intervention 
that is suitable to the current forms of communication and interaction used frequently in 
their everyday lives (22). A further advantage of using this approach is that, if found to be 
effective, it can be easily disseminated, allowing for rapid adoption and scale up at 
regional-level (23). 
 
 
The setting 
 
The prevalence of adolescent suicide in Chile is 8.5 per 100,000 individuals, figures that 
have practically doubled since the 90s (1). Further, the rate of suicidal ideation is extremely 
elevated (30-60%) according to recent reports (15, 24). Among countries included in the 
Organization for Economic Co-operation and Development (OECD), Chile consistently 
presents one of the highest rates of suicide among adolescents (6). Though these 

prevalence rates have fallen slightly in recent years (1), Chile has yet to develop or 
implement a culturally relevant study to reduce youth suicide rates. This shortfall is 
representative of a general lack of evidence-based practices for youth mental health 
conditions, which is unfortunately common in most Latin American countries. 
 
 
Nonetheless, a series of recent reforms on mental health, both at health service- and 
school-level, provide an advantageous scenario to develop and sustain an intervention on 
suicide prevention for the youth in Chile. First, the Ministry of Health has announced that 
suicide among adolescents is a top priority and declared that the reduction of youth suicide 
rates by 10% is one of the top goals of the country’s National Health Strategy for the 
decade 2011-2020 (7). Second, as noted above, a National Plan on Suicide was recently 
launched with the purpose of promoting competencies in the general population in terms of 
self-care, informed lifestyle decisions, and healthy environments that enable suicide 
reduction (8). Third, the development of preventive strategies to reduce self-destructive 
behavior, detect risk factors, and foster protective factors during adolescence (enhancing 
family support, social networks, and community resources) was recently proposed as a 
new component of the Plan (8). It has been recommended that part of such strategies 
should be anchored in school settings (25). Finally, these initiatives have been 
accompanied by an increase in the coverage and technical capacity of national mental 
health services, which have grown and strengthened in the last 15 years (26). 
 
 
As noted above, the evidence for suicide prevention strategies is promising but still 
inconclusive. In addition, the major bulk of this evidence often pertains to interventions 
launched in HICs that cannot be implemented at a large scale in Low and Middle Income 
Countries (LMICs), such as Latin America countries, without local adaptation. Some of 
these interventions are costly and complex and/or are not suited to the service systems 

and sociocultural contexts of the region. A regionally-established evidence base would 
likely be more applicable and persuasive to stakeholders. On the other hand, an approach 
using ICT-based interventions might permit a rapid and feasible scale up, given the high 
use of electronic devices throughout the region. Such interventions could be an effective 
resource to prevent adolescent suicide, especially considering the characteristics and 
idiosyncrasies of the target population. This proposal, therefore, seeks to provide and 
evaluate a program to prevent suicide among adolescents by leveraging technological 
solutions. 
 
 
METHODS/DESIGN 
 
Trial design 
 
This cluster RCT will be conducted in six public secondary schools in three municipalities, 
located in two regions of Chile: two municipalities from the Metropolitan Region (Region 
XIII, where the capital of Santiago is located) and one municipality in the Libertador 
General Bernardo O’Higgins Region (Region VI, to the south of Santiago, which is nearly 
30% rural, in contrast to the Metropolitan Region, which is 3% rural) (27). The study 
procedure consists of six phases (see Figure 1): 1) design of the intervention model and 
creation of prototype; 2) selection of the 6 participating schools; 3) randomization of the 
secondary schools into 3 intervention sites and 3 control sites ; 4) random selection of 6 
courses in each school; 5) presentation of the study and informed consent for parents and 
assent for potential participants; and 6) implementation of the 3-month intervention and 
evaluation at baseline, post-intervention period, and a 2-month follow-up. 
 
 
[Please see Figure 1 below] 

 
Eligibility criteria for trial participants 
 
The study population will consist of adolescents 14 to 18 years of age, who attend 
participating public high schools in the two regions of Chile mentioned above. These two 
regions were selected given the magnitude of their adolescent suicide prevalence rates 
(28) and feasibility considerations for the implementation of the study. Students who have 
visual or physical impairments that are incompatible with the intervention model will be 
excluded. Having a prior diagnosis of a mental disorder will not be considered among the 
exclusion criteria. 
 
 
Recruitment and Screening 
 
A random selection of schools and courses to participate in the study will take place in two 
stages. First, two public schools will be randomly selected from each of the three 
participating municipalities for a selection of a total of six schools. To do so, a list of all 
schools of each type will be drawn up for each municipality. A program will be used to 
randomly order the schools, and relevant authorities from the first school on each list will 
be contacted to invite them to participate in the study. This process will be supported by 
the respective authorities of the educational departments of the municipalities, who have 
already declared their interest and intent to collaborate with the study. Since participation 
is voluntary, schools will have the option to decline the invitation to participate, and if a 
school refuses participation, the next school on the list will be contacted until two schools 
from each municipality have agreed to participate. The first meeting with authorities will 
include a brief description of the study’s objectives and procedures to clarify the 
substantive aspects of its implementation and the concrete support that will be required 
from them. Then, in each municipality, one of the schools will randomly be selected as the 
intervention site and the other will be the control site. Second, we will randomly select six 

courses from each of the six educational establishments. A recent study reported that 
there is an average of 30 students per course in public high schools in Chile (28), so it is 
estimated that these 36 courses will consist of approximately 1,080 students, who will be 
invited to participate in the study with their guardian’s consent and their assent. Even with 
predicted losses due to lack of consent or assent, or meeting exclusion criteria, we expect 
to achieve at least 400 students to complete the recruitment and consent processes (see 
Figure 1), a large enough sample size to detect differences between groups as noted 
below. 
 
 
Randomization and Treatment allocation 
 
To present the study to potential participants, a teacher from the school, a member of the 
research team, and a peer-teenager (between 13 and 20 years of age), who is part of our 
team, will give a short presentation in both the intervention and control schools on the 
importance of mental health and personal and social well-being; in the intervention 
schools, they will also explain how the virtual community-based intervention can improve 
their well-being and serve to support other adolescents in the future. The role of the peer- 
teenager will be to speak from his or her experiences and feelings related to mental health 
conditions (depression, anxiety, suicidal ideation) that are familiar to adolescents (i.e., "this 
also happened to me"), and share part of the collaborative process behind the creation of 
the program. The participating teachers and teenager pairs will be trained by our research 
team and will proceed to invite new participants to the study. 
 
 
The potential participants will then be asked to provide assent (with parent/guardian 
consent) to participate in the intervention or control group. All participants, regardless of 
whether they attend intervention or control schools, will be assessed on three occasions: 
at baseline, after the three-month long intervention, and two months after the end of the 

intervention. The evaluations will be conducted through two approaches with some 
assessments being applied in person by trained mental health professionals and others 
that will be responded by the participants directly via the web platform that will be created 
for the present study. Participants will receive instructions on how to log into the system 
and will be notified at each of the three assessment points. Finally, all information collected 
will be stored digitally in the Data Coordinating Center located in the School of Public 
Health of Universidad de Chile in Santiago, Chile. 
 
 
Interventions 
 
Description of Design of Intervention 
 
In line with the best practices recommended by previous studies (14), peer-adolescents 
were integrated into our multi-disciplinary research team from the beginning of the study, 
to lead and advise the creation of the intervention model by playing a role as “experts by 
experience,” in order to ensure that the project is culturally relevant to the current context 
of high school students in Chile. 
 
 
The “group of experts” – consisting of 7 adolescents, 13 to 20 years of age – were 
recruited and selected through a series of focus groups to reflect the diversity of 
adolescents in Chile, in terms of gender (4 women, 3 men), territorial origin (with members 
from northern, central, and southern regions), high school type (public, private, and 
subsidized schools), socioeconomic level, and sexual orientation. The peer-adolescents 
worked together with three members of the research team (ET a sociologist and public 
health researcher; SS a medical student and public health researcher; and FS a visual 
artist and graphic designer) over the course of six months to create the intervention model, 
on the basis of the literature and the adolescents’ ideas, in light of their own experiences 

and those of their peers (29). 
 
 
 
The ICT-based program utilizes a web-based platform and a mobile application to cultivate 
a virtual community to promote mental health protective factors, such as self-esteem and 
self-expression, and prevent adolescent suicide. To overcome the frequent barriers to help 
seeking, the program will provide rapid direct access to quality, evidence-based 
information and real-time assistance from a mental health professional; encourage habits 
that improve emotional and physical health; facilitate self-monitoring of mental health and 
personal progress; and promote social integration and participation in community-based 
activities. 
 
 
The program is based on the principles of peer support and inclusivity, and as such, its 
name is “Project Clan,” in reference to a diverse group of individuals who come together 
for a common purpose in a welcoming environment. The privacy and anonymity of each 
“Clan member” will be respected, so that they feel free to openly express themselves and 
resolve questions about possibly taboo topics related to mental health and suicide. 
 
 
Project Clan includes both informational and interactive features, ranging from traditional 
suicide prevention strategies (e.g., a chat with a psychologist, emergency phone hotline, 
and tips) that seek to reduce barriers to access quality, useful, and evidence-based 
information and rapid professional assistance, to components designed to increase 
interactions between participants and promote a sense of belonging and connection with 
the other Clan members (see Table 1). 
 
 
[Please see Table 1 below] 

To develop the design concepts for the web-based platform and mobile application – 
including the logo, color schemes, figures, avatars, typeface, and general style – a visual 
artist and graph designer (FS) was incorporated into the research team. He worked closely 
with the “group of experts” to create a visual concept for Project Clan that was esthetically 
attractive, resonated with the adolescent population, and which reflected the principles of 
the intervention. 
 
 
During the three-month intervention, the platform will be continuously monitored by two 
trained psychologists, who will be serve as “counselors” and be available to answer 
community questions and provide support on an individual basis, as well as ensure that 
the rules of the community are followed (such as respect, tolerance, and confidentiality); 
the specific rules will be established by the participants themselves, at the beginning of the 
intervention. Finally, adolescents from the “group of experts”, who played a central role in 
the creation of the intervention model, as noted above, will have access to the platform to 
facilitate discussions especially in the initial stages of the intervention. 
 
 
Intervention arm 
 
Each participant randomized to the intervention group will be assigned a user name and 
password to access both the static and interactive components of Project Clan, and they 
will have complete anonymity, until the counselor supervising the platform identifies 
behaviors associated with suicide risk and proceeds to follow an established emergency 
protocol that is further explained below (see Ethical Considerations). 
 
 
Control arm 
 
Participants in the control group will also be assigned a username and password to access 
the website, but they will be met with a user interface that only displays a space to answer 

the corresponding assessments. In addition to the introductory presentation, they will be 
given a brochure with information regarding adolescent suicide and wellbeing and tips with 
regard to seeking help and assisting others. This will include the contact information for a 
telephone hotline, to ensure they can receive professional help if needed. 
 
 
Fidelity assessment 
 
Fidelity is defined as the degree to which an intervention or program is delivered as 
planned (30). Following the recommendations of the NIH Behavior Change Consortium 
(31), fidelity will be evaluated throughout the trial through a number of approaches. First, a 
manual containing the principles and main strategies of the intervention will be developed. 
Second, on the basis of this manual, a brief scale will be designed and utilized to assess 
the main components of the program at various moments of the intervention (before and 
during implementation). Third, qualitative methods, including in-depth interviews and focus 
groups with deliverers, peers, and participants, will be conducted in order to complement 
the information collected by the fidelity scale. Finally, a thematic matrix will be developed 
with the goal of integrating both quantitative and qualitative findings. 
 
 
Outcomes and Measures 
 
The study’s primary outcome is suicidal ideation measured with the Okasha Suicidality 
Questionnaire (see Table 2 below). Secondary outcomes include other negative 
psychological outcomes (e.g., stigma, depression, anxiety) as well as a number of 
protective psychological and social factors. All measures have been validated for use in 
Chile. 
 
 
[Please see Table 2 below] 

A third set of outcomes will evaluate implementation outcomes such as adoption, utility, 
and functionality of the web-based suicide intervention. “Adoption” indicators will be 
assessed via website metrics, for example, the number of times users sign in and the 
amount of time spent on the platform or with the application each day; the frequency and 
time spent on interactive platform connections; and the use of mental health web 
resources. “Utility” and “Functionality” will be measured via participants’ perspectives 
immediately post-intervention, which will be gathered through a survey administered 
through the study platform. Survey questions will assess the following: a) ease of web 
access; b) satisfaction with the presented contents regarding wellbeing, suicide 
prevention, and the promotion of protective factors; c) ease of use of the interactive 
platform; and d) possible improvements for future applications. These assessments will 
facilitate potential modifications to be incorporated in the platform in future endeavors. 
 
 
Sample size and power calculation 
 
The minimum sample size (n=400) was derived based on a study conducted by Van 
Spijker et al. (11), who also evaluated a web-based suicide intervention for adolescents 
with depression and suicidal ideation. Van Spijker’s study estimated an effect size of d= 
.35 according to Cohen’s parameters (an effect size that is characterized as “small to 
moderate”). In order to detect an effect size of 0.35 with α = 0.05 and b= 0.95, 200 
subjects per arm are needed. Even if 20% loss to follow-up occurs at the 2-month follow- 
up assessment in each group (which is much larger than what was observed in previous 
studies) (12), a sample size of 160 subjects per group with α = 0.05 and b= 0.90 will be still 
able to detect an effect size of 0.35 between groups. Considering the large group of 
potential participants for this study (see Recruitment and Screening), reaching the 
proposed sample size should be feasible. 

Data analysis 
 
An 'intention to treat' approach will be employed to conduct main analyses. The 
assumptions of parametric statistical analysis will be tested (normal distribution, and 
homogeneity of the error variances), and descriptive and bivariate analyses on primary 
(suicidal ideation) and secondary (e.g., depression) outcomes will be performed. In 
addition, a 2X2 multivariate analysis of covariance (MANCOVA) will be conducted to test 
for differences in primary and secondary outcomes between the intervention and control 
groups at baseline vs. post-intervention time points, with and without controlling for a set of 
covariates that include age, gender, education, and family income. Any bivariate 
differences in outcomes will also be examined via regression models controlling for 
covariates. Finally, since 3 time-point assessments will be conducted (baseline, post- 
intervention, and follow-up), multilevel modeling (MLM) for repeated measures will be used 
to compare the effect of the intervention on primary and secondary outcomes by 
evaluation time. 
 
 
Ethical considerations 
 
Pertinent study documents (e.g., research protocol, instruments, informed consent, and 
informed assent forms) were approved by the Ethics Committee for Human Subjects 
Research of the Faculty of Medicine, of Universidad de Chile. In the informed consent and 
assent process, potential participants, and their parents or guardians, if they are under the 
age of 18, will be informed about the possibility to participate in this study and its objective 
and procedures. All participants will be informed of the voluntary nature of this study and 
the possibility to end their participation without affecting in any way their standing or 
access to education at their school, or access to mental health care, should they require it. 
Additionally, confidentiality will be guaranteed, to ensure data integrity and the protection 
of personal information. All in-person evaluations will be conducted by mental health 

professionals, who will receive training on human subjects protection. Participants will be 
given a copy of the consent form, which will contain the contact information for the 
Principal Investigator, in the event of any concern. Information provided by the participants 
will be stored in the Data Coordinating Center at Faculty of Medicine, Universidad de 
Chile. This data will be only handled by research staff, who will be blinded to the status 
(intervention or control) of each participant. 
 
 
None of the activities of the project will have a direct economic cost to the participants. A 
system for reporting and evaluating adverse events will be established (including suicidal 
ideation and suicide attempts). This will consider the notification to the Ethics Committee, 
school authorities, and other relevant institutions, such as mental health services, if a 
suicide attempt occurs. This notification will be made immediately (within 24 hrs.) and the 
process will be directed by the principal investigator (RA). All research team members 
(creators of the intervention, interviewers, counselors, “expert group” teenagers) who 
interact with the participants of this study will be trained in the detection and reporting of 
ideation/suicide attempts. Permanent contact with the Chilean Ministry of Health will be 
maintained, and they will provide support in handling crisis situations and linking 
participants to emergency mental health services emergency if necessary. 
 
 
DISCUSSION 
 
Adolescent suicide has recently gained increased public attention, given the growing 
suicide rates reported worldwide. However, the response from health services and 
educational system is still insufficient. The lack of programs tailored to target this 
population is even worse in LMICs, where significant gaps in mental health services for 
youth have been documented (3). A way to address such gaps is through the use of ICTs, 
in developing and implementing programs that enhance protective factors against suicidal 

behavior. Some evidence from HICs has already shown the potential benefits of such 
programs but further research is needed, especially in settings with restrained resources. 
Providing local evidence is crucial for persuading policy makers and other stakeholders, 
which is critical to ensure that these programs, in case they prove to be effective, could be 
widely disseminated and scaled up. 
 
 
Accordingly, we have described a novel ICT-based program aimed to target youth suicide 
in Chile. This is the first RCT of such a program in Latin America, and to our knowledge, 
the first of its kind in any LMIC. Given the increasing use of technological devices in 
LMICs, this program has the potential to inform future initiatives that seek to introduce ICT- 
based interventions in those countries. 

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Figure 1. Flowchart of the cluster RCT 

 
Component 
Description 
Informational strategies 
Tips 
Evidence-based, professionally approved information, 
adapted by adolescents, on how to find help for oneself 
(from self help to crisis management) and how to help 
others, on risk and protective factors, and other life topics 
(study habits, alimentation, public speaking, recycling, 
exercise, safe sexual practices and general health, etc.). 
Myths versus Realities 
A section to demystify common misconceptions and 
stereotypes about adolescent mental health and suicide 
and other relevant topics. 
Fact sheets 
Infographics and didactic information to share useful dates 
about mental health conditions, bullying, suicide, etc. 
Narratives 
A space for videos and experiences of peers. 
News and calendar 
Relevant local, regional, and international news stories and 
cultural events will be shared. 
Interactive strategies 
Avatars 
To maintain anonymity, members will be able to create 
their profile and have option to a wide range of gender 
neutral personalization options for their avatars. 
Challenges and Points 
To encourage participation and promote personal and 
community development, members of Clan will be offered 
a series of challenges (categorized into personal, social, 
and cultural), and as they complete these challenges, and 
participate in the other activities of the platform, they will 
receive “points”, which will also them access to more 
avatar features, for example, or other benefits. 
Forums 
There will be multiple forums on a range of topics (music, 
movies, sports, anime, politics, news, tv shows, etc.), and 
members can create new topics. A central form will be 
focused specifically on mental health and wellbeing, and 
members will be able to ask the counselor specific 
questions. 
Individual chat 
Members who wish to reach out to counselor on an 
individual basis may do so through a private chat option. 
Emergency hot line 
There will be a telephone number available to call in cases 
of emergency (members feel they are a danger to 
themselves or others). This number will connect to an 
already operational suicide prevention hotline. 
Free Expression Wall 
There will be a central space on the platform in which 
members can anonymously and freely express themselves 
(akin to the graffitied wall of a bathroom stall). 
Mood monitor / Self-evaluation 
Each time they log in, members will have the option to 
respond a quick survey about their mood (with a range of 
faces and space to respond with words, if they wish). 
Feedback 
Members will also have the ability to send their feedback of 
the platform and offer suggestions for its improvement. 
 
Table 1. Description of the intervention 

 
ASSESSMENT 
Domain/Test 
Time 
Description of Instrument 
SOCIODEMOGRAPHIC 
5 min 
Age; gender; education level; family income; school attended (public vs. private) 
PRIMARY OUTCOMES 
Suicidality/ Okasha 
Suicidality 
Questionnaire (32) 
2 
min 
Self-administered instrument exploring ideation and beliefs about suicide. Previously linked to suicide 
intent, depression, despair, low-self-esteem, impulsivity, and low social support. Item is sensitive to 
identifying immediate risk for suicide attempt. 4 items (scale 0-3; scale range= 0-12). Excellent internal 
consistency (Alpha= .89) & sensitivity. 
SECONDARY OUTCOMES 
Self-Esteem/ 
Coopersmith Self- 
Esteem Inventory 
(33) 
10 
min 
Self-report scale on self-esteem among youth and adolescents in personal and social context. 58 items 
(scale 0-1). Good internal consistency (Alpha= .86) & construct validity. 
Impulsivity/ BIS-11 (34) 7 min 
Self-report scale assessing cognitive, motor, and not planned impulsivity. 30 items (scale 0-4). Excellent 
internal consistency (Alpha = .87) & specificity. 
Self-Efficacy/ General 
Self-Efficacy Scale (35) 
4 min 
Self-report scale assessing self-efficacy among youth cross a number of daily stressors. 10 items (scale 1- 
3). Good reliability (Alpha=.79). 
Coping Strategies/ 
Coping Across 
Situations 
Questionnaire (36) 
5 
min 
Self-report scale assessing stress coping strategies among youth. 16 items (scale 1-5). Good reliability 
(Alpha=.63). 
Social support/ 
Perceived Social 
Support Scale (37) 
5 min 
Self-report scale assessing emotional help and advice among youth. 12 items (scale 1-5). Good reliability 
(Alpha=.86). 
Social Skills/ EHS (38) 
8 min 
Self-report scale assessing social skills through self-expression of anger or compliance in difference 
scenarios. 33 items (scale 1-4). Excellent reliability (Alpha=.91) & construct validity 
Depression, Anxiety, 
& Stress/ DASS-21 (39) 
6 min 
Self-report scale assessing depression, anxiety, and stress symptoms. 21 items (scale 0-3). Good reliability 
(Alpha=.87) & construct validity 
Stigma/ Discrimination 
and Devaluation 
Scale(40) 
6 min 
Self-report scale assessing awareness of stereotyping attitudes towards mental illness (12 items) (scale 0- 
3). Good reliability (Alpha= .82) & construct validity 
 
Table 2. Outcomes and measures