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      Developing social capital in implementing a complex intervention: a process evaluation of the early implementation of a suicide prevention intervention in four European countries

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          Abstract

          Background

          Variation in the implementation of complex multilevel interventions can impact on their delivery and outcomes. Few suicide prevention interventions, especially multilevel interventions, have included evaluation of both the process of implementation as well as outcomes. Such evaluation is essential for the replication of interventions, for interpreting and understanding outcomes, and for improving implementation science. This paper reports on a process evaluation of the early implementation stage of an optimised suicide prevention programme (OSPI-Europe) implemented in four European countries.

          Methods

          The process analysis was conducted within the framework of a realist evaluation methodology, and involved case studies of the process of implementation in four European countries. Datasets include: repeated questionnaires to track progress of implementation including delivery of individual activities and their intensity; serial interviews and focus groups with stakeholder groups; and detailed observations at OSPI implementation team meetings.

          Results

          Analysis of local contexts in each of the four countries revealed that the advisory group was a key mechanism that had a substantial impact on the ease of implementation of OSPI interventions, particularly on their ability to recruit to training interventions. However, simply recruiting representatives of key organisations into an advisory group is not sufficient to achieve impact on the delivery of interventions. In order to maximise the potential of high level ‘gatekeepers’, it is necessary to first transform them into OSPI stakeholders. Motivations for OSPI participation as a stakeholder included: personal affinity with the shared goals and target groups within OSPI; the complementary and participatory nature of OSPI that adds value to pre-existing suicide prevention initiatives; and reciprocal reward for participants through access to the extended network capacity that organisations could accrue for themselves and their organisations from participation in OSPI.

          Conclusions

          Exploring the role of advisory groups and the meaning of participation for these participants revealed some key areas for best practice in implementation: careful planning of the composition of the advisory group to access target groups; the importance of establishing common goals; the importance of acknowledging and complementing existing experience and activity; and facilitating an equivalence of benefit from network participation.

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          Most cited references10

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          Best Practice Elements of Multilevel Suicide Prevention Strategies

          Background: Evidence-based best practices for incorporation into an optimal multilevel intervention for suicide prevention should be identifiable in the literature. Aims: To identify effective interventions for the prevention of suicidal behavior. Methods: Review of systematic reviews found in the Pubmed, Cochrane, and DARE databases. Steps include risk-of-bias assessment, data extraction, summarization of best practices, and identification of synergistic potentials of such practices in multilevel approaches. Results: Six relevant systematic reviews were found. Best practices identified as effective were as follows: training general practitioners (GPs) to recognize and treat depression and suicidality, improving accessibility of care for at-risk people, and restricting access to means of suicide. Although no outcomes were reported for multilevel interventions or for synergistic effects of multiple interventions applied together, indirect support was found for possible synergies in particular combinations of interventions within multilevel strategies. Conclusions: A number of evidence-based best practices for the prevention of suicide and suicide attempts were identified. Research is needed on the nature and extent of potential synergistic effects of various preventive activities within multilevel interventions.
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            The alliance against depression: 2-year evaluation of a community-based intervention to reduce suicidality.

            The global burden and large diagnostic and therapeutic deficits associated with depressive disorders call for intervention programs. The aim of the Nuremberg Alliance against Depression (NAD) is to establish and to assess the effectiveness of a four-level intervention program for improving the care of patients with depression. A 2-year intervention program was performed in Nuremberg (480000 inhabitants) at four levels: training of family doctors and support through different methods; a public relations campaign informing about depression; cooperation with community facilitators (teachers, priests, local media, etc.); and support for self-help activities as well as for high-risk groups. The effects of the 2-year intervention on the number of suicidal acts (completed suicides plus suicide attempts, main outcome criterion) were evaluated with respect to a 1-year baseline and a control region (Wuerzburg, 270,000 inhabitants). Compared to the control region, a reduction in frequency of suicidal acts was observed in Nuremberg during the 2-year intervention (2001 v. 2000: -19.4%; p< or =0.082; 2002 v. 2000: -24%, p< or =0.004). Considering suicide attempts only (secondary outcome criterion), the same effect was found (2001 v. 2000: -18.3%, p< or =0.023; 2002 v. 2000: -26.5%, p<0.001). The reduction was most noticeable for high-risk methods (e.g. hanging, jumping, shooting). Concerning completed suicides, there were no significant differences compared to the control region. The NAD appeared to be effective in reducing suicidality. It provides a concept as well as many methods that are currently being implemented in several other intervention regions in Germany and in other countries.
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              The 'European Alliance Against Depression (EAAD)': a multifaceted, community-based action programme against depression and suicidality.

              Action programmes fostering partnerships and bringing together regional and national authorities to promote the care of depressed patients are urgently needed. In 2001 the 'Nuremberg Alliance Against Depression' was initiated as a community-based model project within the large-scale 'German Research Network on Depression and Suicidality' (Kompetenznetz 'Depression, Suizidalität'). The 'Nuremberg Alliance Against Depression' was an action programme, conducted in the city of Nuremberg (500,000 inhabitants) in 2001/2002, addressing four intervention levels (Hegerl et al. Psychol Med 2006;36:1225). Based on the positive results of the Nuremberg project (a significant reduction of suicidal behaviour by more than 20%) 18 international partners representing 16 different European countries established the 'European Alliance Against Depression' (EAAD) in 2004. Based on the four-level approach of the Nuremberg project, all regional partners initiated respective regional intervention programmes addressing depression and suicidality. Evaluation of the activities takes place on regional and international levels. This paper gives a brief overview of the background for and experiences with the EAAD. It describes the components of the programme, provides the rationale for the intervention and outlines the current status of the project. The aim of the paper is to disseminate information about the programme's potential to reduce suicidal behaviour and to provide examples of how European community-based 'best practice' models for improving the care of depressed patients and suicidal persons can be implemented using a bottom-up approach. EAAD is mentioned by the European commission as a best practice example within the Green Paper 'Improving the mental health of the population: Towards a strategy on mental health for the European Union' (European Commission 2005).
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                Author and article information

                Journal
                BMC Public Health
                BMC Public Health
                BMC Public Health
                BioMed Central
                1471-2458
                2013
                20 February 2013
                : 13
                : 158
                Affiliations
                [1 ]Nursing, Midwifery and Allied Health Professions Research Unit, Iris Murdoch Building, University of Stirling, FK9 4LA, Stirling, UK
                [2 ]Suicidal Behaviour Research Laboratory, School of Natural Sciences, University of Stirling, FK9 4LA, Stirling, UK
                [3 ]Department of Psychiatry, University of Pennsylvania School of Medicine, 3535 Market Street, 6th Floor, 19104, Philadelphia, PA, USA
                [4 ]National Suicide Research Foundation, 1 Perrott Avenue, College Road, Cork, Ireland
                [5 ]Institute of Behavioural Sciences, Semmelweis University Budapest, Nagyvárad tér 4, 1089, Budapest, Hungary
                [6 ]CEDOC, Departamento de Saúde Mental, Faculdade de Ciências Médicas da Universidade Nova de Lisboa, 1169-056, Lisbon, Portugal
                [7 ]Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Leipzig AöR, Semmelweisstraße 10, 04103, Leipzig, Germany
                [8 ]LUCAS, Katholieke Universiteit Leuven, Kapucijnenvoer 39 - bus 5310, 3000, Leuven, Belgium
                [9 ]Personal Social Services Research Unit, London School of Economics and Political Science, Houghton Street, WC2A 2AE, London, UK
                [10 ]Klinik und Poliklinik für Psychiatrie, Psychosomatik und Psychotherapie der Universität Würzburg, Füchsleinstraße 15, 97080, Würzburg, Germany
                [11 ]Estonian-Swedish Mental Health and Suicidology Institute, Õie 39, 11615, Tallinn, Estonia
                Article
                1471-2458-13-158
                10.1186/1471-2458-13-158
                3599799
                23425005
                dc79826f-8dbe-4c4a-a102-c1134cfa2579
                Copyright ©2013 Harris et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 2 October 2012
                : 18 February 2013
                Categories
                Research Article

                Public health
                complex interventions,process evaluation,suicide prevention,realist evaluation,social capital,advisory groups

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