Implementation research on community interventions to prevent repeated suicide attempts among individuals in low-resource settings in Ningxia, China and Nunavut, Canada Two projects, in China and Canada to prevent repetition of suicide attempts. PI China: Michael Phillips Director, Suicide Research and Prevention Center, Shanghai Mental Health  Center,  Shanghai Jiao Tong University School of Medicine Executive Director, WHO Collaborating Center for Research and Training in Suicide Prevention,  Beijing Huilongguan Hospital Professor of Clinical Psychiatry and Clinical Epidemiology, Columbia University Along with many collaborators PI Canada: Brian L. Mishara Director, Centre for Research and Intervention on Suicide, Ethical Issues and End of Life Practices, Professor, Psychology Department, Université du Québec à Montréal Along with Allison Crawford, Jack Hicks and a large number of Agencies and Community Partners

Aims and Objectives The China and the Canada Project both: Focus on a demonstrated high risk group for death by suicide and a repeated attempt: persons seen in hospital of a suicide attempt Implement a proven intervention to reduce suicide recidivism: the SUPRE-MISS protocol developed by WHO, involving regular community non-professional follow-up after discharge from hospital Interventions are developed in collaboration with communities, and are adapted to local cultures and ressources Implementation science approach to evaluation, combined with assessment of outcome measures

Principal Investigators for Canadian Project Canadian Project: Prevention of repeated suicide attempts in Nunavut, Canada by community follow-up adapted to Inuit culture Principal Investigators for Canadian Project Brian L. Mishara, Ph. D., Directeur, Centre de recherche et d’intervention sur le suicide et l’euthanasie (CRISE), Professeur, Département de psychologie; Allison Crawford, M.D. Assistant Professor, Department of Psychiatry, University of Toronto, Directrice du Northern Psychiatric Outreach Program and Telepsychiatry, Centre for Addiction and Mental Health, Directrice, Psychiatry outreach services to Nunavut; Jack Hicks, Ph. D. Cand., Ilisimatusarfik (The University of Greenland), Adjunct Professor, Department of Community Health & Epidemiology, College of Medicine, University of Saskatchewan Kimberly Masson, Embrace Life Council, Nunavut

Inuit village near Frobisher Bay, from Hall (1865)

Suicide by Inuit in Nunavut, and Canada (all) 1970-2015

Suicide by Inuit in Nunavut, by sex and age group

-- ‘Suicide’, Napatchie Pootoogook, Cape Dorset, 1997-8.

Our approach Collaboration between researchers, community organizations, members of communities, in decision making at all stages of the development, planning, implementation, evaluation, interpretation of results and dissemination of results.

  Task /Milestone YEAR 1 (2018) YEAR 2 (2019) YEAR 3 (2020) YEAR 4 (2021) YEAR 5 (2022) 1-2 3-4 5-6 7-8 9-10 11-12 PHASE 1. (8-month qualitative ‘situation analysis’ and adaptation consultations) IRB approval at UQAM and Nunavut, meeting of participants, hiring coordinator Establish suicide attempt notification system with hospital and health workers Focus groups and consultations with various stakeholders Determine preliminary method of conducting and evaluating the intervention in communities and choose 1 or 2 communities) for feasibility testing PHASE 2. (1-year feasibility testing of adapted version of SUPRE-MISS intervention) Train community workers and implement intervention and in method of conducing ongoing evaluation of intervention in 1 or 2 communities Conduct implementation and evaluation with continued feedback and monitoring Revise intervention based on process evaluation of the intervention in the target communities. PHASE 3. (30-month implementation of revised intervention in the original communities and ‘scaling-up’ to additional communities) Work with communities’ stakeholders to monitor suicide attempts in target communities Using methods developed in Phase I, conduct ‘situation analysis’ and adapt intervention to characteristics additional communities Enroll individuals treated for suicide attempts in the participating communities Provide social support, training of family and community providers, and emergency back-up services for enrolled individuals Conduct follow-up assessments of enrolled individuals at 1m, 6m,12m, 18m and 24 m for all enrollees, and meetings with community leaders and stakeholders PHASE 4. (Project evaluation and dissemination) Quantitative assessment of outcome measures Qualitative evaluation of feasibility and outcome of intervention from perspective of stakeholders and participants Publication of results Promote the dissemination of intervention to all communities in Nunavut by Embrace Life Council members, including Government of Nunavut, to the other 3 Inuit territories in Canada by ITK, to other indigenous populations, and to other LMICs countries interested in addressing the issue of suicide (by the WHO)

Challenges Coordonnating a project in isolated villages accessible only by air, each with different ressources; after patients return from the (only) hospital in Iqaluit, usually over 1000 km away. Ensuring adaptation of interventions to local culture and ressources, and uptake by target population High costs of everything in Nunavut, including personnel for project.

Principal Investigators for China Project China Project: Prevention of repeated suicide attempts in Nunavut, Canada by community follow-up adapted to Inuit culture Principal Investigators for China Project Michael Phillips Director, Suicide Research and Prevention Center, Shanghai Mental Health  Center,  Shanghai Jiao Tong University School of Medicine Executive Director, WHO Collaborating Center for Research and Training in Suicide Prevention,  Beijing Huilongguan Hospital Professor of Clinical Psychiatry and Clinical Epidemiology, Columbia University

Community intervention to prevent repeated suicide attempts in Ningxia Province, China The project in China will implement and evaluate an adapted version of the WHO SUPREMISS project (previously proven effective in China) to all 44 level-2 and level-3 general hospitals in Ningxia PREPARATION：Develop an accidental injury registry system and associated attempted suicide registry in the ED of at all 44 county-level and higher general hospitals in Ningxia Province PHASE 1：In-depth interviews and focus groups with relevant stakeholders in 4 of Ningxia’s 22 counties to assess (and subsequently revise) the feasibility of the WHO SUPRE-MISS intervention previous used for suicide attempters in Shandong Province: including a 45 interview and educational intervention about suicide in the ED, a home visit within 2 weeks of discharge to identify and train a local ‘guardian’, and quarterly home visits to provide social support and re-assessments over the next 2 years. PHASE 2：A pilot test of the revised intervention in 6 hospitals in the 4 target counties for 1 year PHASE 3：Revise the intervention based on the pilot, implement it in the EDs of 18 hospitals in 12 counties, and then compare the suicide rates and suicide attempt repeat rates over the subsequent 2 years in the 12 intervention counties with that in the 10 non-intervention counties PHASE 4：Conduct in-depth interviews and focus groups with stakeholders to determine their attitudes about the feasibility and effectiveness of the intervention; combine the quantitative and qualitative to prepare a report and use the report to promulgate the intervention throughout Ningxia, in other provinces in China, and to low-resourced settings in other LMICs interested in suicide prevention. EXPECTED OUTCOME: A manual for developing and promulgating an effective suicide prevention strategy for low-resourced settings in LMICs

Implementation research on community interventions to prevent repeated suicide attempts among individuals in low-resource settings in Ningxia, China and Nunavut, Canada Two projects, in China and Canada to prevent repetition of suicide attempts. PI China: Michael Phillips Director, Suicide Research and Prevention Center, Shanghai Mental Health  Center,  Shanghai Jiao Tong University School of Medicine Executive Director, WHO Collaborating Center for Research and Training in Suicide Prevention,  Beijing Huilongguan Hospital Professor of Clinical Psychiatry and Clinical Epidemiology, Columbia University Along with many collaborators PI Canada: Brian L. Mishara Director, Centre for Research and Intervention on Suicide, Ethical Issues and End of Life Practices, Professor, Psychology Department, Université du Québec à Montréal Along with Allison Crawford, Jack Hicks and a large number of Agencies and Community Partners