Innovation summary

One of the main public mental health challenges facing Iran in the recent decade is the increasing rate of suicide, especially in some provinces of the country1. After piloting an action research program in Khoram Abad (Lorestan province) and Nahavand (Hamedan province) in 2007, the National Integrated Suicide Prevention Program had been implemented throughout the country. Subsequent efforts in evaluating the project have since been implemented to analyze the Program's impact. In addition to providing treatment and care, the program also provides aftercare services (brief psychosocial intervention and telephone follow-up) for individuals who attempted suicide and presented at emergency departments in four western provinces.

The National Suicide Prevention Program underwent recent revisions by national and international experts and a new version was scaled up to include the following goals and strategies:

  1. Improved registration of people who attempt suicide
  2. Reduction of stigma associated with suicide
  3. Increasing availability and provision of services through Primary Health Care
  4. Involvement of and engagement with Media to improve the quality of reporting suicide attempts
  5. Reducing the easy access to common means of suicide 
  6. Improving research activities to understand the epidemiology and risk factors of suicide in the country

Impact summary

  • Preliminary data analysis of suicide trends shows promising results of a 57.6% reduction in suicide mortality proportion in an experimental city over a 2% reduction in control city

“We have been able to control the high rate of suicide within a narrow range in the past 10 years, and we will be able to decrease the rate with the enhancement of inter-sectoral collaboration in the future.” 

  - Program Staff Member

Innovation details

One of the primary public mental health challenges facing Iran in the recent decade is the mild increasing rate of suicide especially in some provinces of the country1. We have performed several evaluation projects to analyze whether the National Integrated Suicide Program has been working effectively.

After piloting an action research program in Khoram Abad (Lorestan province) and Nahavand (Hamedan province) back in 2007, the national integrated suicide prevention had been implemented throughout the country. In addition to providing treatment and care, the program also provides aftercare services (brief intervention & telephone follow-up) for people who attempt suicide presented at emergency departments in four western provinces.

The Revised 'National Suicide Prevention Program'

After piloting some action research projects and evaluating the national suicide prevention program and national suicide web-based program, by national and international expert team, the new version and scaled up the National Suicide Prevention Program was developed. The following main goals and related strategies were planned:

  1. Improving the registration system to track national suicide trends
    • Involved increasing the validity of the data
    • Collaboration with forensic medicine department
    • Providing regular reports
    • Optimizing access to real-time data
  2. Reduce the social stigma around suicide
    • Through engagement in the public education system
    • Re-education within the leadership and governance of the health system
  3. Increasing service provision and access to mental health and psychiatric services
    1. Increase the quality and quantity of services
    2. Management of at-risk cases in PHC
    3. Management the at-risk cases by specialists
    4. Management at-risk cases by psychologists
    5. Providing postvention services
    6. Providing consistent and continuous services for at risk individuals
  4. Media
    1. To improve the quality of reflecting the news about suicide attempts and behaviours 
  5. Access to mean
    1. Reduce access to lethal means of suicide
  6. Research activities
    1. To perform at least two Health Services Research projects in each province
    2. Encouraging the Deputy of Research in each medical university in at-risk provinces to allocate a particular budget on this issue

The project for integration of the program into the Primary Health Care

  1. Establishing a steering committee for the integration of the programme into the PHC (at provincial level), including:
    1.  Dean of the universities, deputies of health and treatment, psychiatrists working in the community at different levels
    2. The governor of the district to encourage inter-sectoral linkages with other related departments, e.g. regular meeting with the High Council for Health and Food.
  2. Designing, developing and implementing a training plan:
    1. Developing training manuals for different tiers of health staff
    2. Executing the training session by Waterfall model to cover the health staff
    3. Evaluating the impact on knowledge and attitude changes through a pre-post test
    4. Re-training (and refresher trainings) plan
  3. Enhancing the registration system
    1. Re-training the responsible staff
    2. Monitoring data entry closely 
    3. Controlling the pathway system and flow of the data
  4. Increasing access to health services and treatment facilities
    1. Provision of required psychiatric beds
    2. Establishing outpatient services/consultation office
    3. Provision of ECT
    4. Provision of required staff particularly psychiatrists
  5. Improvement of screening efforts for early detection of those at risk
    1. Providing screening tools adjusting to the local culture
    2. Training on the utilization of screening tools
    3. Implementing the screening tools to identify at risk cases
  6. Effective Monitoring and Evaluation and providing regular feedback to:
    1. Local officials
    2. Steering committees

The project for evaluation of the aftercare program

  1. Establishing a steering committee including:
    1. At national level, MoH, police department and welfare organizations
    2. At provincial level (four provinces) including the dean of the university, deputy of curative and health affairs and welfare organizations
    3. Assigning the eligible cities to implement the programs (Criteria including, existence of hospital space and capacity of health staff)
  2. Training manuals
    1. Providing educational manual for Emergency Department personnel
    2. Providing educational brochures for attempters and their families presented at EDs
    3. Training manual for brief consultation according to ASSIP method
  3. Drawing referral pathway
    1. Designing/clearing the referral pathway from Emergency Departments (hospital/treatment sector) to the District Health Centre (health sector) and finally to Comprehensive Health Centre (psychologist to provide brief intervention and follow-up by telephone)
  4. Monitoring and correction of reporting system on the registration web-based network
    1. Re-training on the use of the registration system 
    2. Monitoring closely to evaluate timely reporting
  5. Designing telephone follow-up program and data sheet registration
  6. Monitoring every three months

 

The Newly Revised National Program:

This program addresses enhancing preventive actions for suicide across the health system and sectors involved. The main goal of the program is to reduce the rate of suicide attempts, behaviours and death rates in the Iranian population with the following strategic objectives:

  • Enhancing the registration system
  • Reducing the social stigma around suicide awareness activities
  • Increasing access to mental health and psychiatric services
  • Proper management of the media coverage of suicide
  •  Decreasing access to lethal means of suicide
  • Upscaling of research on all aspects of suicide

Key drivers

  • The Leadership role of the Ministry of Health in the implementation process
    • Inclusion of guidelines for action within high-level policy documents such as the 6th National Development Plan
  • Engagement with NGOs who have strong links with the community

Challenges

  • There is a need for stronger health infrastructure, especially as a foundation for better referral pathways
  • Inter-sectoral collaboration is still a work in progress with regards to implementing the Integrated Suicide National Program
  • Stigma around suicide and low levels of mental health literacy act as a key barrier for public engagement with the Program
  • The improper distribution of skilled professionals plays a key challenge in the implementation of the Program
  • Inadequacy of research and data banks to record the statistics associated with suicide in the country

Continuation

The National Suicide Prevention Program has been informed by locally conducted research and based on other national and international evidence. Nested evaluation projects up-scaling the program have been implemented throughout the last 10 years. 

In 2019, the new and revised National Suicide Prevention Program based on the results of the latest evaluation of the program in 4 Western provinces will be implemented countrywide and evaluated in 2 provinces. 

Partners

  1. Iran Scientific Society for Suicide Prevention
  2. The National Welfare Organization
  3. The Forensic Medicine Organization
  4. The Police Department
  5. The Ministry of Interior Affairs
  6. The Ministry of Education
  7. The Ministry of Higher Education
  8. The Ministry of Agricultures
  9. The Judiciary Department
  10. International Association for Suicide Prevention (IASP)
  11. WHO/GENEVA

Funder

  1. Ministry of Interior Affairs
  2. WHO/EMRO, for international monitoring and evaluation

Evaluation methods

Process for the evaluation of the existing National Program

  1. Providing a standardized and holistic executive framework by international experts
  2. Reviewing the available documents and articles and providing a summary of results
  3. Visiting the western provinces and monitoring the program scrutiny by national evaluation team
  4. Visiting some central provinces and monitoring the program by international experts
  5. Using rapid assessment evaluation method to evaluate the program
  6. Providing the report and recommendation to scale up the national suicide prevention program and registry
  7. Using the suggestions and recommendations to provide the new version of national suicide prevention and registry programs

Evaluation of the registration system took place over 5 provinces in Iran and consisted of the following components:

  1. Reviewing the practice manual for establishing and maintaining surveillance systems for suicide attempts and self-harm (WHO 2016)
  2. Monitoring the implemented registry program
  3. Modifying and enhancing the online registry program

The primary method of evaluation was based on the rapid appraisal method which included:

  • Conducting in depth interviews with key participants
  • Group meetings and discussion with health staff
  • Field observations
  • Observation of the documentation of the performed program

In the process of modification of the program, the following tools and indicators were used:

  • The monitoring checklists, provided by the expert national team (based on WHO normative guidelines)
  • The data registry sheets
  • The knowledge of the health staff
  • The registry pathway and timing
  • The referral paper forms
  • The availability of educational brochures
  • The number of meetings supposed to be held regularly at district’s governor office and the minutes
  • The regular reports provided by the mental health officer of the district and the manager of mental health of the province
  • The number of identified cases
  • The quality of collaboration of other sectors based on expert opinion

Cost of implementation

Total Annual Cost of the National Suicide Program:

  • Ministry of Health and Medical Education: 33,000,000 USD (1.4 thousand billion IRR) annually

Total Cost of the Annual Evaluation:

  • The Ministry of Health and Medical Education (extra budget for aftercare project): 47,000 USD (2000 milion IRR) for 2017
  • WHO/EMRO: 13,500 USD for international monitoring and evaluation for 2016 

Impact details

Results from evaluation:

  • The rate of suicide mortality in the control city was 19.3 reduced to 18.9 per 100000 in one year.
  • In the experimental city the suicide mortality fell from 12.5 to 5.3 per 100000 people in one year (p<0.05)

Results from aftercare study:

  • In control cities the suicide rate increased from 9.75 to 11 per 100000 people.
  • In experimental cities from suicide rate decreased from 7.19 to 7.03 in one year (no significant differences).

References

  1. Ghanbari, B., Malakouti, S. K., Nojomi, M., De Leo, D., &amp; Saeed, K. (2016). Alcohol abuse and suicide attempt in Iran: a case-crossover study. Global journal of health science, 8(7), 58.
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Country

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