Practical lessons learnt from the worldwide implementation of 115 community-based interventions for suicidal prevention

Abstract Background Depression and other psychiatric disorders are the main cause for suicidal behaviour. The community based 4-level-intervention concept adapted by the “European Alliance against Depression” (www.EAAD.net) has been found to have preventive effects not only on depression but also on suicidal behavior in several but not all controlled studies. The 4-level intervention concept comprises training and support of primary care providers (level 1), a professional public relation campaign (level 2), training of community facilitators (teacher, priests, geriatric care givers, pharmacists, journalists) (level 3), and support for self-help of patients with depression and their relatives (level 4). Methods This 4-level intervention has in the meanwhile been implemented in more than 115 regions worldwide. A systematic assessment of the practical experiences, as well as a systematic process analysis and an implementation research were performed. Results Important findings of this research are: i) the relevance of a strong bottom-up element in the implementation process, ii) the synergistic and catalytic effects generated by becoming simultaneously active at the four different intervention levels, and iii) the crucial advantage of combining the partly overlapping topics of depression and prevention of suicidal behaviour. The latter approach is highly relevant having in mind the unclear risk-benefit-balance of anti-suicidal public campaigns, which are likely to result in a lowering of the threshold by normalization of suicidal behavior. More detailed information on these findings will be presented. Conclusions Systematic research on the on-going community based 4-level intervention program can add useful insights in suicide prevention strategies.

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Community-based 4-level approach: Background, implementation and evidence for efficacy

European Psychiatry ◽

10.1016/j.eurpsy.2016.01.858 ◽

2016 ◽

Vol 33 (S1) ◽

pp. S31-S32 ◽

Cited By ~ 1

Author(s):

U. Hegerl ◽

E. Arensman ◽

C. van Audenhove ◽

T. Baader ◽

R. Gusmão ◽

...

Keyword(s):

Suicidal Behavior ◽

Process Analysis ◽

Primary Care Providers ◽

Successful Implementation ◽

Care Providers ◽

Community Based ◽

Community Based Programs ◽

Intermediate Outcomes ◽

Level 3 ◽

Competing Interest

The community-based 4-level-intervention concept developed within the “European Alliance against Depression” (http://www.eaad.net/) combines two important aims: to improve the care and treatment of patients with depression and to prevent suicidal behavior. It has been shown to be effective concerning the prevention of suicidal behavior [1–4] and is worldwide the most broadly implemented community-based intervention targeting depression and suicidal behavior. The 4-level intervention concept comprises training and support of primary care providers (level 1), a professional public relation campaign (level 2), training of community facilitators (teacher, priests, geriatric caregivers, pharmacists, journalists) (level 3), and support for self-help of patients with depression and for their relatives (level 4). In order to deepen the understanding of factors influencing the effectiveness of the intervention, a systematic implementation research and process analysis was performed within the EU-funded study “Optimizing Suicide Prevention Programs and Their Implementation in Europe” (http://www.ospi-europe.com/; 7th Framework Programme) [5]. These analyses were based on data from four intervention and four control regions from four European countries. In addition to intervention effects on suicidal behaviour, a variety of intermediate outcomes (e.g. changes in attitude or knowledge in different populations) were considered. Strong synergistic as well as catalytic effects were identified as a result of being active simultaneously at four different levels. Predictable and unpredictable obstacles to a successful implementation of such community-based programs will be discussed. Via the EAAD, the intervention concept and materials (available in eight different languages) are offered to interested region in and outside of Europe.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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European Alliance Against Depression: Person centered care for depression and prevention of suicidal behaviour

The International Journal of Person Centered Medicine ◽

10.5750/ijpcm.v6i3.587 ◽

2016 ◽

Vol 6 (3) ◽

pp. 174-179

Author(s):

Ulrich Hegerl ◽

Ella Arensman ◽

Elisabeth Kohls

Keyword(s):

Suicidal Behavior ◽

Public Awareness ◽

Primary Care Providers ◽

Successful Implementation ◽

Care Providers ◽

Community Based ◽

Care Givers ◽

Community Based Programs ◽

Intermediate Outcomes ◽

Centered Care

Background: Depression is a prevalent and severe disorder and a major cause for attempted and completed suicides in Europe. Objectives: The community-based 4-level-intervention concept developed within the “European Alliance against Depression” (EAAD; www.eaad.net) combines two important objectives: to improve the care and treatment of patients with depression and to prevent suicidal behavior. Methods: The EAAD community-based 4-level intervention comprises training and support of primary care providers (level 1), a professional public awareness campaign (level 2), training of community facilitators (teachers, priests, geriatric care givers, pharmacists, journalists) (level 3), and support for self-help of persons suffering from depression and for their relatives (level 4). Results: Several studies evaluated different aspects of the 4-level community-based intervention concept over the past years and showed a significant reduction in suicidal behavior and various changes in intermediate outcomes (e.g. changes in attitude or knowledge in different populations). Systematic process evaluation was helpful to identify several predictable and unpredictable obstacles to a successful implementation of such community-based programs as well as synergistic and catalytic effects.Conclusions: The EAAD community-based interventionhas been shown to be effective concerning the prevention of suicidal behavior and is the most broadly implemented community-based intervention targeting depression and suicidal behavior world-wide. Via the EAAD and partners from currently 22 countries from in- and outside of Europe, the intervention concept and materials (available in many different languages) are offered to interested regions.

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Linkage to primary-care public health facilities for cardiovascular disease prevention: a community-based cohort study from urban slums in India

BMJ Open ◽

10.1136/bmjopen-2020-045997 ◽

2021 ◽

Vol 11 (8) ◽

pp. e045997

Author(s):

Abhijit Pakhare ◽

Ankur Joshi ◽

Rasha Anwar ◽

Khushbu Dubey ◽

Sanjeev Kumar ◽

...

Keyword(s):

Public Health ◽

Primary Care ◽

Multivariate Analysis ◽

Urban Slum ◽

Primary Care Providers ◽

Health Facilities ◽

Care Providers ◽

Community Based ◽

Public Health Facilities ◽

Care Facilities

ObjectivesHypertension and diabetes mellitus are important risk factors for cardiovascular diseases (CVDs). Once identified with these conditions, individuals need to be linked to primary healthcare system for initiation of lifestyle modifications, pharmacotherapy and maintenance of therapies to achieve optimal blood pressure and glycaemic control. In the current study, we evaluated predictors and barriers for non-linkage to primary-care public health facilities for CVD risk reduction.MethodsWe conducted a community-based longitudinal study in 16 urban slum clusters in central India. Community health workers (CHWs) in each urban slum cluster screened all adults, aged 30 years or more for hypertension and diabetes, and those positively screened were sought to be linked to urban primary health centres (UPHCs). We performed univariate and multivariate analysis to identify independent predictors for non-linkage to primary-care providers. We conducted in-depth assessment in 10% of all positively screened, to identify key barriers that potentially prevented linkages to primary-care facilities.ResultsOf 6174 individuals screened, 1451 (23.5%; 95% CI 22.5 to 24.6) were identified as high risk and required linkage to primary-care facilities. Out of these, 544 (37.5%) were linked to public primary-care facilities and 259 (17.8%) to private providers. Of the remaining, 506 (34.9%) did not get linked to any provider and 142 (9.8%) defaulted after initial linkages (treatment interrupters). On multivariate analysis, as compared with those linked to public primary-care facilities, those who were not linked had age less than 45 years (OR 2.2 (95% CI 1.3 to 3.5)), were in lowest wealth quintile (OR 1.8 (95% CI 1.1 to 2.9), resided beyond a kilometre from UPHC (OR 1.7 (95% CI 1.2 to 2.4) and were engaged late by CHWs (OR 2.6 (95% CI 1.8 to 3.7)). Despite having comparable knowledge level, denial about their risk status and lack of family support were key barriers in this group.ConclusionsThis study demonstrates feasibility of CHW-based strategy in promoting linkages to primary-care facilities.

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The 4-Level Approach: Prevention of Suicidal Behaviour Through Community-Based Intervention

Frontiers in Psychiatry ◽

10.3389/fpsyt.2021.760491 ◽

2021 ◽

Vol 12 ◽

Author(s):

Ulrich Hegerl ◽

Ines Heinz ◽

Ainslie O'Connor ◽

Hannah Reich

Keyword(s):

Public Health ◽

Primary Care ◽

High Risk ◽

Suicidal Behaviour ◽

Lessons Learned ◽

Community Based Interventions ◽

Community Based ◽

Four Levels ◽

The Many ◽

Different Levels

Due to the many different factors contributing to diagnostic and therapeutic deficits concerning depression and the risk of suicidal behaviour, community-based interventions combining different measures are considered the most efficient way to address these important areas of public health. The network of the European Alliance Against Depression has implemented in more than 120 regions within and outside of Europe community-based 4-level-interventions that combine activities at four levels: (i) primary care, (ii) general public, (iii) community facilitators and gatekeepers (e.g., police, journalists, caregivers, pharmacists, and teachers), and (iv) patients, individuals at high risk and their relatives. This review will discuss lessons learned from these broad implementation activities. These include targeting depression and suicidal behaviour within one approach; being simultaneously active on the four different levels; promoting bottom-up initiatives; and avoiding any cooperation with the pharmaceutical industry for reasons of credibility.

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Facilitating treatment of HCV in primary care in regional Australia: closing the access gap

Frontline Gastroenterology ◽

10.1136/flgastro-2018-101049 ◽

2018 ◽

Vol 10 (3) ◽

pp. 210-216 ◽

Cited By ~ 3

Author(s):

Lauren White ◽

Ali Azzam ◽

Lauren Burrage ◽

Clare Orme ◽

Barbara Kay ◽

...

Keyword(s):

Primary Care ◽

Secondary Care ◽

Transient Elastography ◽

Liver Stiffness ◽

Primary Care Providers ◽

Treatment Recommendation ◽

Care Providers ◽

Hcv Treatment ◽

Community Based

BackgroundAustralia has unrestricted access to direct-acting antivirals (DAA) for hepatitis C virus (HCV) treatment. In order to increase access to treatment, primary care providers are able to prescribe DAA after fibrosis assessment and specialist consultation. Transient elastography (TE) is recommended prior to commencement of HCV treatment; however, TE is rarely available outside secondary care centres in Australia and therefore a requirement for TE could represent a barrier to access to HCV treatment in primary care.ObjectivesIn order to bridge this access gap, we developed a community-based TE service across the Sunshine Coast and Wide Bay areas of Queensland.DesignRetrospective analysis of a prospectively recorded HCV treatment database.InterventionsA nurse-led service equipped with two mobile Fibroscan units assesses patients in eight locations across regional Queensland. Patients are referred into the service via primary care and undergo nurse-led TE at a location convenient to the patient. Patients are discussed at a weekly multidisciplinary team meeting and a treatment recommendation made to the referring GP. Treatment is initiated and monitored in primary care. Patients with cirrhosis are offered follow-up in secondary care.Results327 patients have undergone assessment and commenced treatment in primary care. Median age 48 years (IQR 38–56), 66% male. 57% genotype 1, 40% genotype 3; 82% treatment naïve; 10% had cirrhosis (liver stiffness >12.5 kPa). The majority were treated with sofosbuvir-based regimens. 26% treated with 8-week regimens. All patients had treatment prescribed and monitored in primary care. Telephone follow-up to confirm sustained virological response (SVR) was performed by clinic nurses. 147 patients remain on treatment. 180 patients have completed treatment. SVR data were not available for 19 patients (lost to follow-up). Intention-to-treat SVR rate was 85.5%. In patients with complete data SVR rate was 95.6%.ConclusionCommunity-based TE assessment facilitates access to HCV treatment in primary care with excellent SVR rates.

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Redefining the Care Continuum to Create a Pipeline to Dementia Care for Minority Populations

Journal of Primary Care & Community Health ◽

10.1177/2150132720921680 ◽

2020 ◽

Vol 11 ◽

pp. 215013272092168

Author(s):

Tina R. Sadarangani ◽

Vanessa Salcedo ◽

Joshua Chodosh ◽

Simona Kwon ◽

Chau Trinh-Shevrin ◽

...

Keyword(s):

Alzheimer’S Disease ◽

Primary Care ◽

Alzheimer's Disease ◽

Asian American ◽

Minority Groups ◽

Primary Care Providers ◽

Dementia Care ◽

Care Providers ◽

Community Based ◽

Community Based Organizations

Multiple studies show that racial and ethnic minorities with low socioeconomic status are diagnosed with Alzheimer’s disease and Alzheimer’s disease–related dementias (AD/ADRD) in more advanced disease stages, receive fewer formal services, and have worse health outcomes. For primary care providers confronting this challenge, community-based organizations can be key partners in supporting earlier identification of AD/ADRD and earlier entry into treatment, especially for minority groups. The New York University Center for the Study of Asian American Health, set out to culturally adapt and translate The Kickstart-Assess-Evaluate-Refer (KAER) framework created by the Gerontological Society of America to support earlier detection of dementia in Asian American communities and assist in this community-clinical coordinated care. We found that CBOs play a vital role in dementia care, and are often the first point of contact for concerns around cognitive impairment in ethnically diverse communities. A major strength of these centers is that they provide culturally appropriate group education that focuses on whole group quality of life, rather than singling out any individual. They also offer holistic family-centered care and staff have a deep understanding of cultural and social issues that affect care, including family dynamics. For primary care providers confronting the challenge of delivering evidence-based dementia care in the context of the busy primary care settings, community-based organizations can be key partners in supporting earlier identification of AD/ADRD and earlier entry into treatment, especially for minority groups.

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Is the Far West Mental Health Integration Project Making a Difference? The General Practitioner Perspective

Australian Journal of Primary Health ◽

10.1071/py05040 ◽

2005 ◽

Vol 11 (3) ◽

pp. 32 ◽

Cited By ~ 1

Author(s):

David Perkins ◽

David Lyle

Keyword(s):

Mental Health ◽

Primary Care ◽

Health Care ◽

Primary Care Providers ◽

Care Staff ◽

Care Providers ◽

Community Based ◽

Mental Health Integration ◽

Integration Project ◽

The Impact

This paper reports on the evaluation of an Australian Government and NSW State funded Mental Health Integration Project in remote far western NSW. The project was part of the Mental Health Integration Program, developed from the Second National Mental Health Plan. The project implemented a model of community-based mental health services and used innovative financing arrangements to allow the provision of community-based specialist mental health teams to remote communities and to recruit visiting psychiatrists to support the local primary care providers. The evaluation strategy included a survey of general practitioners (GPs) in the Upper Western Sector and Broken Hill, designed to investigate their level and type of contact with psychiatrists and community-based specialist mental health care teams, their perceptions about the impact of the new services, and their interest in further professional development in mental health care.The project has shown that visiting specialists can be deployed in a primary care setting with a focus on meeting the needs of local GPs, primary health care staff and their patients.

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Lack of harms from community-based melanoma screening by primary care providers

Cancer ◽

10.1002/cncr.30194 ◽

2016 ◽

Vol 122 (20) ◽

pp. 3102-3105

Author(s):

Clara Curiel-Lewandrowski ◽

Susan M. Swetter

Keyword(s):

Primary Care ◽

Primary Care Providers ◽

Care Providers ◽

Community Based ◽

Melanoma Screening

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Reaching Out to Rural Caregivers and Veterans with Dementia Utilizing Clinical Video-Telehealth

10.20944/preprints201804.0229.v1 ◽

2018 ◽

Author(s):

James S. Powers ◽

Jennifer Buckner

Keyword(s):

Primary Care ◽

Rural Areas ◽

Primary Care Clinic ◽

Primary Care Providers ◽

Dementia Care ◽

Mental Health Provider ◽

Care Providers ◽

Community Based ◽

Term Care ◽

Care Clinic

Context: A clinical video telehealth (CVT) program was implemented improve access and quality of dementia care to patients and their caregivers in rural areas. The program was offered as part of an established dementia clinic/geriatric primary care clinic in collaboration with five community-based outpatient clinics (CBOC’s) affiliated with the Tennessee Valley Healthcare System (TVHS) in middle Tennessee. Telehealth support was provided by a physician – social worker team visit. Methods: Telehealth training and equipment were provided to clinic personnel, functioning part-time with other collateral clinical duties. Patients and caregivers were referred by primary care providers and had an average of 1 to 2 CVT encounters originating at their local CBOC lasting 20 to 30 minutes. Clinical characteristics and outcomes of patients and caregivers receiving CVT support were collected by retrospective electronic medical record (EMR) review. Results: Over a 3-year period 45 CVT encounters were performed on patient-caregiver pairs, followed for a mean of 15 (1-36) months. Some 80% patients had dementia confirmed and 89% of these had serious medical comorbidities, took an average of 8 medications, and resided at a distance of 103 (76-148) miles from the medical center. Dementia patients included 33% with late stage dementia, 25% received additional care from a mental health provider, 23% took antipsychotic medications, 19% transitioned to a higher level of care, and 19% expired an average of 10.2 months following consultation. Caregiver distress was present in 47% of family members. Consult recommendations included 64% community-based long-term care services and supports (LTSS), 36% medications, and 22% further diagnostic testing. Acceptance of the CVT encounter was 98%, with 8770 travel miles saved. Conclusion: CVT is well received and may be helpful in providing dementia care and supporting dementia caregivers to obtain LTSS for high-need older adults in rural areas.

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Online Health Promotion to Reduce Cancer Risk: Lessons From Learning With Alaska’s Tribal Primary Care Providers

Journal of Global Oncology ◽

10.1200/jgo.18.40100 ◽

2018 ◽

Vol 4 (Supplement 2) ◽

pp. 16s-16s

Author(s):

K. Cueva ◽

M. Cueva ◽

L. Revels ◽

M. Hensel ◽

M. Dignan

Keyword(s):

Primary Care ◽

Online Learning ◽

Cancer Risk ◽

Online Education ◽

Health Care Providers ◽

Primary Care Providers ◽

Cancer Information ◽

Advisory Group ◽

Care Providers ◽

Community Based

Background: Alaska's tribal primary care providers in rural Alaska - community health aides and practitioners (CHA/Ps) - requested online education about cancer for themselves and their communities. Aim: A research team at the Alaska Native Tribal Health Consortium engaged in community-based participatory action research to develop culturally respectful online cancer education to support CHA/Ps to increase their knowledge, reduce their own cancer risk, and share cancer information. Methods: This project created ten online learning modules, a semester-long online course that combined the modules with synchronous conversations, and a supplemental webinar series. All modules were community-based and collaboratively developed with input from a community advisory group of CHA/Ps, content experts, and interested partners. Learners completed an evaluation survey at the end of each module and webinar. Course participants completed a precourse assessment, and evaluations at the end of each module, at the end of the course, two-months postcourse, and six-months postcourse. Results: While evaluation is ongoing, as of March 2018, 194 unique individuals, including 27 course participants, had completed 1,288 module evaluation surveys. Learners reported an increase in cancer knowledge, and intentions to reduce their personal cancer risk and share cancer information as a result of the online learning. On 98% of completed surveys, learners shared that they planned to change their interactions with patients as a result of the learning, including talking more about cancer screening, cutting down/quitting tobacco, being more physically active, and eating healthy. A total of 88% of unique learners planned to reduce their personal cancer risk as a result of the learning, including by quitting tobacco, having recommended cancer screenings, exercising, and eating healthier. Comparison of pre and postcourse survey responses showed CHA/Ps’ had changed to eat more fruits and vegetables and exercise more, as well as felt more knowledgeable about cancer, and more comfortable both with finding medically-accurate cancer information online and talking to their patients, families, and communities about cancer. Conclusion: This culturally respectful education strategy may be adaptable to other populations to support primary care providers and their communities to reduce cancer risk. This intervention may be of particular interest to health care providers, public health professionals, and those interested in health systems in rural and remote regions and in areas with limited medical infrastructure.

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