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SPIRIT Hub Project Summary


DR. SHIELDS-ZEEMAN: Hi, everyone. I'm here today on behalf of the PI team from the SPIRIT hub, which is the Suicide Prevention and Implementation Research Initiative. Unfortunately, Soumitra and Lakshmi couldn't do this presentation, so I'll be doing it on our behalf.

Just to give a quick recap, the main research institutions involved in the SPIRIT hub are the Centre for Mental Health Law and Policy at the Indian Law Society, where Soumitra and Lakshmi are based, and the Trimbos Institute, which is the Dutch institute for mental health and addiction, which is also doing a lot of the research and capacity-building efforts and implementation science.

We work closely in both India and Bangladesh with government agencies such as the Department of Health and Family Welfare for the government of Gujarat, and also public health services, including the Gujarat Institute for Mental Health, and specialized public health services, such as the Psychiatric Hospital for Mental Health in Ahmedabad. And we work with nongovernmental organizations, both in India. That's SNEHA, a suicide prevention NGO that Lakshmi leads and the Bangladesh Centre for Communication Programs, who is an active partner in our administrative supplements, to design a community surveillance system for suicide attempts and death by suicide, to report and capture that data better, and also an active partner in our capacity-building work.

As a recap, what is SPIRIT trying to do? Our focus is really on reducing suicide attempts and deaths by suicide through implementation and evaluation of a suicide prevention program that's multifaceted across different sectors. So we don't stick to just the healthcare sector, but we also work in the social, education, agricultural sectors, since we know that suicide is a multifaceted problem, and we want to make sure that our intervention touches upon collaboration and stakeholders from these different domains.

On the right, you can see as a refresher where we work in India and which specific district, which is Mehsana district, we implement the intervention in.
What are we implementing and evaluating? We first of all implemented a locally adapted version of the Youth Aware of Mental Health Program. That's a mental promotion intervention for 14- and 15-year-olds, adapted from the Karolinska Institute in Sweden, which is really focused on increasing awareness in mental health, developing healthy coping strategies, and encouraging help-seeking behavior as well as peer support.

The second is community storage facilities. Those are centralized community storage facilities for pesticides, for farming households to safely store when they're not in use. And last, but not least, we've focused on developing and implementing a locally adapted version of the WHO intervention guide, specifically their module on suicidal ideation and self-harm, which has a set of concrete steps for identification of high-risk behavior and referral to mental health professionals, and this is specifically implemented in SPIRIT through community health workers.

In addition to these three interventions, we've also designed and implemented a surveillance system to account for some of the shortcomings and challenges in data reporting related to deaths by suicide and suicide attempts, and I'll explain a little bit more about that later and where we're at with that currently.

Despite the COVID-19 pandemic, we've actually reached a lot of people in the community in the last few years through our scaleup study and our capacity-building hub. We've been able to provide access to safe storage of pesticides for many households, 156,000 people from the community. There's an active group of 4,900 people storing their pesticides in our existing community storage units. We've reached almost 2,500 students through the YAM program, and we've reached 60 beneficiaries so far who are identified to be at risk and had a referral to specialized mental healthcare through use and implementation of the WHO mhGAP intervention guide by community health workers.

A little bit more about the community surveillance system that I just mentioned. We really saw this as emerging from a need to develop a systematic process to collect more information on cases of attempted suicide and deaths by suicide. What we did is to really collect data from key informants who are approached every month to gather data. We gather data from different sources, and this is also then crosschecked and cross-verified to arrive at a triangulated case of an attempted or a death by suicide. So the community surveillance that you can see below on the left-hand side complements the data that's collected through hospital records and through the police records as well.

Concretely, here you can see an example of how that system adds value in practice. You see in the middle row here that the cases that were identified by police and hospital records in a given period were 91. But when we look at the cases that were additionally identified, we see that there's quite a lot of cases that our community surveillance system identified that were not captured in the police and hospital records. So this is really an important source of data to be able to get a more comprehensive picture of the problem in a given region or community.

For those interested in reading a bit more about how we designed this community surveillance system, we published a protocol paper outlining our process and lessons learned in BMJ Open last year.

In terms of an intervention update from the Youth Aware of Mental Health program, we've actually reached 2,500 students, and this is about what we expected to reach, and we've been able to give the full program. So that's five sessions that take place in five hours over about three weeks to about 75 percent of the students. The rest have got a partial dose, maybe only completed a few sessions and dropped out. So we're doing pretty well in terms of our expected dose to a maximum number of students.

As I mentioned, this is really a culturally sensitive mental health promotion program that took almost a year for us to adapt for the Indian context, and unfortunately, some of the schools, although it was only seven, could not implement YAM due to COVID or other priorities once schools did reopen after COVID.

These are pictures below of the students, the pupils from the schools, and below are the trainers that are actually delivering the YAM sessions in the schools. As you can see, we're currently busy still with collecting data at 3-month follow-up, which is due this month, and 12-month follow-up, which is due in January, 2023. So that's one of the reasons why we've extended the trial and the data collection for this purpose.

You can see here that in the control arm we've also been collecting baseline 3-month and follow-up data, primarily on depression, anxiety, and suicidal ideation. There have been some dropouts as well, and also there have been challenges in collecting data due to COVID-19 restrictions locally.

When we look at our second intervention, the community storage facilities, as you can see, on the right-hand side, this is what they look like in practice. So really concrete structures that are in a dedicated, centralized space in the village that are authorized and approved by the local governments in the intervention villages. We really focused on storing pesticides here, as that's one of the most common means to die by suicide in the region. Any member from the village who is active in agricultural activities can use the lockers free of charge, and we've also, as part of the intervention, trained facility managers who oversee the facility and monitor the check-in and checkout of pesticides.

As you can see, we do have a varying usage rate; 58 percent is quite good, from our standards. But a number of people have actually signed up for the lockers, and we do see over time a stable signup and use of the lockers over time. So we don't see any trends that would suggest that there's been a declining rate in their use, even now with the COVID-19 pandemic.

For the last intervention update, the mhGAP training for community health workers, we again, similar to the YAM, spent a lot of time locally adapting the mhGAP intervention guide for self-harm and suicide, and we made sure to train a variety of different types of community health workers who are active in Mehsana district in Gujarat.

The community health workers have been trained to assess and identify people at risk, provide brief psychological support or motivational interviewing, and also provide referrals to more specialized primary healthcare mental health services or specialized mental health services.

As you can see, we're also collecting data at baseline as well as 6-month and 12-month follow-up in terms of how the intervention guide has been implemented, how many referrals there have been to specialized care, how many of those referrals have actually been realized by people actually seeking care afterwards, and we're still collecting that data on an ongoing basis, similar to what we're doing for YAM, so that's going to continue until next year.

As you can see, in the control villages we're also collecting data there, and there has been quite a few dropouts, especially with our 12-month follow-up data.
I also just briefly wanted to touch upon the additional promotional activities that we've done, in addition to the intervention implementation. We wanted to make sure that we engage communities, local communities, during the implementation process. We've done that through, for example, a short play where we tried to really encourage through actors the experiences of mental health issues, boost mental health awareness, and engage dialogue also among the audience members.

This is an example of a community resource list for mental health promotion that was available in a number of places in the community and in the health centers where community health workers are active. And this an example of a poster that was hung up in various places in the village to promote the use and the benefits of using a community storage facility.

We've also tried to do a few nice activities, thinking outside of the box, like giving out awards and having a small ceremony for exceptional performers who are implementers either from the community storage facilities, such as the facility managers, or community health workers active in using the mhGAP algorithm guide.

I just want to say a few words about our capacity-building core in the SPIRIT project. We had an ambitious set of goals in our capacity-building core. That includes contributing to fielding implementation science skills in mental health in South Asia, really equipping policymakers with the insights they need for mental health and suicide prevention research, and how that can be better used in policy, and also to really work with community members with documenting what's happening during the implementation process and what their role could be in further sustaining these interventions and suicide prevention initiatives after the SPIRIT project ends.

I'll start with our update on the policymaker workshops. In the last period since the COVID-19 pandemic started, we did do one session at the national training academy for policymakers in India. We had 80 participants, and this was really focused on common beliefs and breaking myths about mental health and suicide, talking about some basic principles related to mental health promotion and mental health awareness, and discussion about what current policy landscapes look like for mental health in India.

Our plans this year are later to work with local and district-level policymakers, so that more local than the national training academy, on how to use knowledge and research findings in policy decisions locally.

The second was our contribution to building implementation science capacity in mental health in South Asia. Our initial goal was to have a cohort of 30 fellows from both India and Bangladesh. We're now in our third year of the fellowship program, and we've had 36 fellows enrolled for the fellowship, not all of them have completed the fellowship or have dropped out, partially due to many of them having responsibilities as healthcare professionals during the pandemic. But we still expect to reach 90 percent of the target for fellows, so we expect to have 27 complete the full course.

The fellowships consist of intensive training, lectures, interactive discussions, question-and-answer sessions, as well as an in vivo study visit to Mehsana, where they can actually how the SPIRIT intervention is implemented. During the pandemic, we had to of course change course, so we moved the in vivo study to online, and we also changed the format of the final project, which was originally based on data collection from the in vivo study visit, and we moved that towards more feasible targets, like writing an implementation research proposal or operationalizing a conceptual framework for implementation science related to mental health interventions.

We also did something a bit different that wasn't originally envisaged in our capacity-building core. We offered and developed a self-paced course for media professional to improve reporting of mental health and suicide events, using evidence-based guidelines. This is freely available on Moodle. We've already had 105 media professionals join, and a number of them haven't fully completed the course, but have at least started, but of course that's self-paced, that can be done at any time. And there are a number of modules, such as pre- and post-knowledge assessments of your level of knowledge about mental health, interactive presentations, reflective questions, guided exercises by the SPIRIT team, quizzes, and also a series of videos and narratives and stories of people with lived experience.

It has actually had a positive impact on a number of media professionals. Here you can see the benefit that it's brought to certain media professionals in India. We also are offering this to other members who are working in media in low- and middle-income countries.

Last but not least, I mentioned earlier that we really wanted to do workshops with community members and bring the community together to discuss how to maintain and keep the interventions for suicide prevention going in the community. These sessions were disrupted due to the pandemic, but they are planned for the third quarter of 2022, once the scaleup plans for the three interventions have been finished in terms of their rollout in the district.

Prior to the pandemic, you can also see here, some of the community-level meetings that we held, and we're looking forward to continuing that later this year.
That's all for an update. Happy to discuss throughout the course of the conference any further questions you have about SPIRIT.

Thanks very much.