The engaged community action for preventing suicide (ECAPS) model in Latin America: development of the ¡PEDIR! program

Abstract

Purpose

It is estimated that someone dies by suicide every 40 s globally and that 3000 people end their lives daily. Of these deaths, 79% occur in low-resource settings. The very nature of the low-resource settings often serves as a barrier to the adoption and implementation of evidence-based suicide prevention models that have demonstrated success in high-resource countries. As such rates of suicide continue to increase, the workforce of trained mental health providers equipped to effectively engage, assess, and treat individuals struggling with suicidal thoughts and behaviors remains relatively stagnant. This paper aims to illustrate the implementation of the Engaged Community Action for Preventing Suicide (ECAPS) model as a means of developing a culturally relevant and responsive model of suicide prevention that is acceptable and sustainable in low-resource settings.

Methods

University faculty and staff (n=34) and psychology students (n=25), and community-based mental health providers (n=41) providing mental health services to at-risk individuals in highly vulnerable communities in Lima, Peru participated in the implementation of ECAPS process.

Results

The resulting program, ¡PEDIR!, demonstrates the acceptability, feasibility, and effectiveness of the ECAPS model.

Conclusion

The ECAPS model is a feasible and effective framework for use in low-resource settings to guide the development of a culturally relevant community-level intervention to address the systemic, societal, and individual level factors that serve as barriers to suicide prevention.

Background

It is estimated that someone dies by suicide every 40s globally and that 3000 people end their lives daily [1]. However, it is important to note that even this rate is considered a significant underestimate due to a lack of reporting due to structural stigma resulting from cultural and religious attitudes and beliefs, legal consequences related to suicide, variance in the manner in which deaths are recorded across countries in terms of cause and method (i.e., asphyxia versus hanging), and overall absence of a system for registering deaths by suicide [2]. In addition to barriers related to accessing mental health care, other community-level challenges in these settings include extreme poverty, food insecurity, inadequate housing and educational and employment opportunities, to name a few. Suicide rates in low-income countries (often referred to as “low-resource settings” (LRS) due to the lack of resources for the provision of adequate healthcare services) are particularly concerning. While the age-standardized rate of suicide is generally somewhat higher in high-income countries (HICs) than in low- and middle-income countries (LMICs) [3], 79% of suicides occur in low-resource settings [1]. Additionally, research consistently demonstrates that suicide attempts are more prevalent than suicide ideation among LMIC populations [4–6]. Despite this over-representation of suicide risk in LMICs, research on suicide prevention is disproportionately centered in high-income countries with only 10% of investigations focused on LMICs, begging the question as to how we can effectively intervene with suicidal behavior where it most often occurs if we are not studying that population. For example, over 80% of suicidal behavior in high-income countries are linked to psychiatric illness whereas only 45% are in LMICs [7]. Without an accurate understanding of the psychosocial and economic determinants of suicidal behavior in LMICs, health systems are unlikely to be able to provide effective prevention or intervention programs or to have adequate human resources to support those at risk of engaging in suicidal behavior [8].

The very nature of the low-resource settings themselves often serves as a barrier to the adoption and implementation of evidence-based suicide prevention models that have demonstrated success in high-resource countries. Evidence-based practice (EBPs) models are difficult to translate to LRS for several reasons. To begin with, they tend to be based on structures of supervision and case consultation that rest on foreign experts. This is not sustainable due to financial and time constraints and limits the impact and growth of the prevention effort. Further, they often involve pre-determined training content grounded in Western, high-resource experiences, values, and expectations. This significantly limits their applicability in LRS, particularly with respect to indigenous populations within LRS who tend to have the highest rates of suicide and maintain traditional customs, values, and language. Additionally, EBPs often have pre-determined targets of prevention, such as means restriction. In many LRS like Peru, common means of suicide involves ingestion of poisonous plants that are naturally growing in the Amazon [9, 10]. In such a context, means restriction is not viable. Lastly, EBPs require strict adherence for fidelity purposes and to achieve the demonstrated effectiveness. Yet, when delivered as designed/manualized, they once again fail to address the contextual characteristics and qualities of LRS and, hence, are limited in their applicability.

In addition to increased risk of suicide, the picture is equally grim with respect to mental health-related disparities. More than 70% of the global mental health burden occurs in these LRS [11]. Depression is especially prevalent and has been found to be the most disabling disorder worldwide as measured by years lived with disease (YLDS) [1]. Yet, rates indicate that as many as 90% of people in low- and middle-income countries do not receive any treatment for their depression [12–14]. It has been noted that the ratio of burden to resources available for mental health care in low-resource countries is exceptionally inequitable and is worse than in all other major health areas [15, 16]. The detrimental consequences of mental illness are even more amplified in LRS, as they increase risk not only for non-communicable and communicable diseases, but also the risk of suicide [17]. This is particularly problematic in Latin American and the Caribbean (LAC) where over 80% of countries are low- and middle-income. In fact, suicide has been identified as one of the greatest public mental health challenges for the next decade in Latin America and the Caribbean (LAC) [18].

‬Peru has traditionally ranked among the countries with the lowest rates of suicide in South America [18]. However, suicide rates sharply increased between 2007 and 2010 [19], reflecting, perhaps, the significant political turmoil occurring in the nation at the time, with the extradition and trial of former president Fujimoro for human rights violations, corruption, and murder and several significant protests by indigenous leaders/communities, resulting in violent protests, refueling sentiments of exclusion and discrimination. Suicide rates then steadily declined from 2010 until 2016 when they once again experienced a significant increase which has continued to this day [19]. Suicide rates are consistently 2–3 times higher among males in Peru [18]. Research also indicates that the age range with the highest incidence of suicide is 20–29 years (28.7%) [18] and that hanging is the most common suicide method among both males (59%) and females (48%) [20, 21]. Among adolescents, research has found that 26.3% reported having suicidal ideation in the past year, and 17.5% reported suicide attempt in the past year [21]. However, these data are considered significant underestimates, as it is estimated that in Peru, for every 10 suicides, only 4 are reported [22]. Alarmingly, data indicate that despite the increasing prevalence of suicide, the rates of those receiving needed mental health treatment to mitigate risks are as low as approximately 30% in Lima and less than 7% in other provinces [23].

Contributing to this significant mental health treatment gap are: (1) systemic factors, such as an insufficient budget allocated to mental health care (less than 1% GDP), and centralized facilities for mental health; (2) societal factors, such as stigma, lack of information regarding mental health symptoms and treatment, and lack of confidence in medical personnel; and (3) individual level factors such as at-risk individuals thinking they can solve their problems independently, considering themselves incapable of help, lacking awareness of where to seek mental health treatment, and financial and/or time constraints [24–26].

The engaged community action for preventing suicide (ECAPS) Model was developed as an approach to suicide prevention in low-resource settings to address these systemic, societal, and individual level factors [25]. ECAPS consists of 7 key steps including (1) Identifying the relevant determinants specific to the community associated with suicide risk; (2) Assessing the resources available (and not available) in the community; (3) Prioritizing determinants according to available resources; (4) Developing a change strategy; (5) Implementing the strategy; (6) Evaluating outcomes; and (7) Identifying next steps (Table 1). ECAPS addresses the limitations of other conventional suicide prevention models that are developed in high-resource settings and brought to low-income countries for implementation that are led by a foreign expert and neglect to account for the unique systemic, social, and individual-level factors specific to the LRS. Without this contextual grounding, even efforts to adapt these conventional models to the LRS will not prove effective, as they tend to provide superficial modifications to language to include cultural idioms of distress or illness explanatory models, and/or rely on the knowledge and expertise of foreign leaders to drive the process of intervention program implementation and delivery [27].

Table 1.

Engaged community action for suicide prevention (ECAPS) steps and components

Step 1. Identify the relevant determinants associated with suicide risk specific to the community	In-depth focus groups with key community constituents’ regarding community’s struggles, resources, strengths, challenges, barriers to care, drivers of suicide and potential sources of resilience and coping
Step 2. Assess the resources available (and not available) in the community	Identify the existing resources available within the community for modifying those social determinants from the local constituent perspective
	Identify resources that may need to be enhanced or restored or those that may be lacking altogether and in need of development
Step 3. Prioritize determinants according to available resources	Identify the resources that will be harnessed to address goals that can be realistically achieved in a short amount of time, reinforcing the belief that change is possible and empowering communities to take action
	Identify resources that can be brought into the process at a later date to work toward longer-term goals that may take more time to achieve
Step 4. Develop a change strategy	Local leadership, in collaboration with the outside facilitator, identify potential strategies and plans of action that will be implemented in the community to effect change and reduce suicide risk that is culturally relevant and responsiveness
	Local leadership then determines the specific strategies that will be implemented and the mechanisms to sustain the strategies moving forward
	Procedures for evaluation of progress and overall impact should be included
Step 5. Implement the strategy	Implement the developed program
	Implementation should be led by local
	leadership with facilitators playing a collaborative, supportive role ensuring the community is well-positioned to maintain the strategies moving forward once the outside facilitators are no longer present
Step 6. Evaluate outcomes	Evaluate the degree impact of the program based on procedures determined in Step 4
	Determine whether additional measures are needed to maintain the benefits experienced, further grow the impact of the strategies in place, implement new strategies that can further strengthen any benefits that may have been experienced, or problem-solve barriers that limited the success of the strategies developed
Step 7. Identify next steps	Identify mechanisms for sustaining and growing the efforts put into place
	These can be drawn, in part, from prioritizing the goals in Step 3. Others will be drawn from the evaluation of outcomes in Step 6
	As the program is incorporated into the community, attention to maintaining and modifying the program is important to ensure it remains timely, relevant, and responsive to the new context. Hence, identifying procedures for on-going monitoring of gains and potential setbacks is vital

ECAPS addresses these barriers in several key ways. ECAPS is centered on a community-based participatory approach that supports cross-cultural partnerships and resource sharing and shared decision-making power. It prioritizes the local constituents’ identification of relevant social determinants of health related to suicide risk that are present in their community. It prefers local expertise of community members and fosters the empowerment of community leadership to drive and sustain needed action. ECAPS is grounded in a process of mutual learning that emphasizes active participation in the training process and leverages mechanisms for maintaining, sustaining, and growing the network of lay providers capable of assessing and managing suicide risk, such as the use of technology. It further addresses the historical trauma, discrimination, and marginalization of certain groups in LRS, resulting in a distrust of authority by positioning local leaders to guide the prevention strategy development and implementation process.

This paper reports on the implementation of ECAPS in Lima, Peru, and the model of suicide prevention, the ¡PEDIR Program, which grew out of the ECAPS application. The ¡PEDIR! Program consists of two key components—provider training and education development. At the provider training level, ¡PEDIR! (Preparar, Evaluar, Determinar, Intervenir, Reforzar/ASK! (Prepare, Evaluate, Determine, Intervene, Reinforce)), aims to train individuals to ASK about suicidal thoughts and feelings and to: Prepare providers to engage with clients around suicidality by increasing self-awareness of attitudes, biases, assumptions regarding suicide; Evaluate relevant risk and protective factors; make a Determination regarding the client’s level of risk; Intervene with evidence-based strategies; and, Reinforce gains made in treatment.

At the provider level, ¡PEDIR! targets provider knowledge, attitudes, and skills through 5 key modules, including: (1) key factors in youth development related to suicide risk; (2) self-awareness regarding attitudes, values, beliefs toward suicide; (3) core components of suicide risk assessment; (4) help-seeking and evidence-informed strategies for engaging at-risk individuals in treatment; and, (5) intervention strategies and tools for intervening with at-risk individuals (Table 2). At the educational level, ¡PEDIR! offers curriculum development aimed at undergraduate and graduate mental health programs (psychology and counseling) with three goals: (1) developing relevant curriculum on suicide assessment and intervention; (2) training faculty to effectively teach this content; and, (3) training current students in these programs on this content to ensure the next generation of mental health providers entering the field is skilled in effectively engaging with, assessing and treating at-risk individuals. The specific content of the ¡PEDIR! training modules has been described elsewhere (see [28]). This paper aims to illustrate the implementation of ECAPS as a means for developing a culturally relevant and responsive model of suicide prevention that is acceptable and sustainable in low-resource settings.

Table 2.

¡PEDIR! provider training module components

Module 1. Key factors in youth development related to suicide risk	Cognitive Abilities (i.e., abstract thinking skills, reasoning skills, etc.)
	Identify Formation (i.e., role definition, sense of values and purpose, etc.)
	Autonomy (i.e., trust and emotional bonding, strive for independence, caregiver expectations and availability, etc.)
Module 2. Self-awareness regarding attitudes, values, beliefs toward suicide	Self-awareness and recognizing one's own values, beliefs and attitudes toward suicide that influence provider engagement and effectiveness when interacting with at-risk youth
	Common myths and misconceptions and assumptions regarding suicide
Module 3. Core components of suicide risk assessment	Current standards for risk assessment including: recognizing warning signs; core questioning areas (i.e., ideation, plan, intent, etc.); identifying and understanding key risk/protective factors for youth; important clinical considerations in determining severity of risk (i.e., capacity to act, perceived lethality, rehearsal, likelihood of rescue, etc.)
Module 4. Help-seeking and evidence-informed strategies for engaging at-risk youth in treatment	Relevant cultural values and attitudes toward suicide that impact help-seeking and engagement in treatment (i.e., familismo, fatalism, etc.)
Module 5. Intervention strategies and tools for intervening with at-risk youth	Brief, concrete, evidence-informed treatment strategies including, safety planning and Cognitive Behavior Treatment (CBT) strategies of identifying, challenging, and modifying negative automatic thoughts

Methods

University faculty and staff (34), and psychologists and graduate students in the psychology program (25), as well as community-based mental health providers across disciplines (psychiatry, psychology, counseling, and psychiatric nursing) (N = 41) participated in various stages of the ECAPS process. The number of participants at various steps of the process is noted in the implementation section. Participants were employed in various settings (schools, hospitals, community-based health teams) actively providing mental health services to at-risk individuals in highly vulnerable communities in Lima, Peru.

The Director of Psychological Services at a University in Lima, Peru, contacted practicing mental health professionals in local organizations/schools/hospitals with which the University collaborates to recruit key constituents to participate in focus groups to discuss their perspectives on risk and protective factors for suicide in their community, the state of mental health care in Peru, their personal mental health training experiences, and their practice experience with individuals at risk of suicide. No remuneration for participation was offered, and participation was strictly voluntary with no impact on the clinicians’ standing with their respective employers. They were able to leave the focus group at any time or to refrain from answering any questions if they chose to do so. Informed consent to participate was sought from all clinicians before the focus groups were held.

Academic-research partnership

As a member of a global association of Jesuit universities, the home institution of the study PI boosts a commitment to support Jesuit institutions across the globe. The local Jesuit University in Lima, Peru, has a history of student immersion programs and research collaborations with the study PI’s home institution in the United States. This relationship facilitated initial outreach to the local university to engage in a discussion of social problems in the local community, including increasing risk of suicide in the country. However, the on-going working relationship was formed on the basis of several key principles that served to establish trust—including an understanding of the responsibility of the study PI to respect the autonomy of the local university, the emphasis on locally driven capacity building, and the dual benefit of collaboration and exchange of knowledge and expertise. The local University, respected by the community, was then positioned to present the mutually beneficial collaboration to key constituents in their local network, increasing trust and facilitating buy-in with community members.

ECAPS implementation

Step 1: Identify the relevant social determinants

To begin the ECAPS process, 4 focus groups were held. Participants included 32 mental health professionals (13 psychiatrists, 16 psychologists, 2 psychiatric nurses, 1 social assistant) (see [25] for details). All participants were currently providing services to families and individuals in high-risk communities where suicide was identified as a key community concern. Average years of practice experience of participants was approximately 8 years. The focus groups, conducted in Spanish by a United States-based PhD level professor of social work, with over 20 years of experience as a mental health clinician and researcher in the field of suicidology, along with a PhD level psychologist working as a professor and the director of psychology in a Jesuit University in Peru Groups, lasted 1.5 h on average. Data were collected using a semi-structured interview developed by the study PI, informed by the little existing evidence regarding suicide risk in Peru and following the ECAPS framework. The following general topics were explored: (1) quality and nature of education and training on suicide assessment and intervention; (2) quality and nature of existing mental health resources in the community available to at-risk individuals; (3) barriers to and facilitators of treatment engagement of at-risk individuals; (4) relevant social determinants of health related to suicide risk in the community; (5) protective factors and sources of resilience in the community; (6) other relevant points of information meaningful to the community members that had not yet been discussed that could inform the development of a strategy for addressing suicide risk in their community.

Detailed field notes were taken by the PI during the focus groups—a widely accepted approach in qualitative research as a means of documenting contextual and process information [25, 28], providing a rich context for analysis [29–32]. The field notes were taken in accordance with established guidelines for the collection, integration, and evaluation of focus groups notes [25, 28]. The field notes were then transcribed and checked for accuracy and authenticity by the primary author and a Spanish-speaking MSW-level graduate assistant. Each reviewed the transcription independently to identify units of information that referred to the same content. Consensus meetings were then held to review coding, reach agreement and achieve consistency during the course of the analysis [33, 34]. Using an inductive approach, the identified units were then collapsed to create a set of preliminary categories which were then clustered. From these final clusters, key themes were identified.

Step 2: Assess community resources

Participants in the focus group identified several relevant social determinants of health related to suicide risk in their community as potential points of intervention. Most notably, they determined that of the 10 predominant social determinants of health, poor access to care, stigma, and limited understanding of mental illness (symptoms and treatment), and adverse life experiences were strongly influencing risk in the community.

In terms of access to care, participants noted the primary barrier to care above and beyond financial constraints and location of services, is the lack of mental health professionals with specialized training on suicide assessment and intervention. They explained that suicide assessment and intervention are not part of the training curricula in any graduate mental health, internship, or residency program in any mental health discipline (psychology, psychiatry, etc.). Participants noted they lacked the skills and knowledge to adequately support at-risk individuals.

Regarding stigma and limited understanding of mental illness, participants noted that the perception that suicide is illegal in Peru serves as a barrier to reporting suicidal thoughts and feelings. Additionally, they noted that there is a lack of understanding of mental illness in the general population, with individuals struggling with mental health problems often labeled as crazy, misunderstood, and excluded.

Lastly, regarding adverse life experiences, participants noted the negative consequences of civil conflict, reporting that the period of conflict interrupted the traditional role of family, with elders unavailable to serve as sources of strength, wisdom, and guidance, resulting in a lack of role models for the younger generation. They also noted the devastating consequences of rampant domestic violence and violence against women and girls and explained that even when services are provided to victims of violence, they generally do not address mental health needs.

Step 3: Prioritize social determinants by available resources

In prioritizing the social determinants identified in Step 2, participants felt strongly that addressing the lack of human capital available to provide care to at-risk individuals was the most important determinant to address and the one that had the most potential to make a significant impact in a short amount of time. It was their position that providing psychoeducation to reduce stigma would increase the help-seeking behaviors of at-risk individuals. However, if the providers were not trained to help them, they would have nowhere to seek help even though they might be ready to accept it. Participants further explained that to address access barriers and decentralize centers of care, the government had in recent years created a policy and allocated funding for the establishment of community mental health teams. They identified several ways in which the community teams improved the likelihood that at-risk individuals could receive the help they need, including triaging cases, providing referrals, and offering support to less severe cases. However, they also identified that, despite government support, there are not enough of these centers to make a meaningful impact. For example, in 2018, the Health Ministry estimated that Perú needed 315 community mental health teams and, up until that time, only 31 such teams existed [25]. Further, at the primary care level, they added that doctors could serve as a source of referral to community mental health teams but, at present, often lack the knowledge and skills needed to identify mental health issues and therefore are unable to take advantage of their position to link at-risk individuals to services. As an existing structure for providing care existed, despite being underdeveloped, participants felt that providing specialized training to members of the existing mental health teams was a first key step in addressing rising suicide rates. Additionally, they determined that key lay professionals in the community where teams did not yet exist, namely teachers and school counselors, could also be trained to assess and manage suicide risk, and that university curriculum could be developed to prepare the next generation of mental health professionals entering the field to serve at-risk individuals.

Step 4: Develop a change strategy

Community leaders determined that developing and implementing a training program for mental health professionals, school personnel, and University staff, faculty, and graduate students would be the most effective, feasible, and timely way to address the priority identified. The goals established were threefold: (1) equip existing mental health and lay professionals with the skills, knowledge, and attitude needed to effectively engage and treat at-risk individuals, (2) develop a system for on-going peer supervision and case consultation; and (3) develop a curriculum to train future mental health trainees in suicide risk and assessment.

To address these goals, a specialized brief training program was developed to address attitudes toward at-risk individuals, targeting skills and knowledge of suicide assessment and brief, concrete evidence-informed intervention strategies to reduce risk. ¡PEDIR! (Preparar, Evaluar, Determinar, Intervenir, Reforzar/ASK! (Prepare, Evaluate, Determine, Intervene, Reinforce)), aims to train individuals to ASK about suicidal thoughts and feelings and to: Prepare to engage with clients around suicidality by increasing self-awareness of attitudes, biases, assumptions regarding suicide; Evaluate relevant risk and protective factors; make a Determination regarding the client’s level of risk; Intervene with evidence-based strategies; and, Reinforce gains made in treatment.

In terms of monitoring and evaluation, questionnaires that included open-ended questions as well as items rated on a 5-point Likert scale were developed to assess participants’ self-reported attitudes and beliefs regarding suicide, knowledge of assessment and intervention with suicidal individuals, and skills at assessing and intervening with individuals struggling with suicidal thoughts and feelings. Questionnaires were administered by the trainers at baseline on the first day of training prior to the start of the program to establish pre-training scores. They were then administered upon training completion to determine the acceptability and effectiveness of the training at improving attitudes toward suicide; increasing knowledge of risk and protective factors, and assessment and intervention strategies; and improving skill at engaging, assessing, and working with at-risk individuals. Scores on pre- and post-test were reviewed by the community leaders and the training team to establish if the goals of the training were achieved. A follow-up assessment was scheduled for 6 months post training to determine if the benefits of the training persisted over time. Lastly, it was agreed that training retention rates would further be used as a measure of acceptability.

Additionally, the training was manualized to allow for a training-of-trainers model (TOT) to be built into the program. Individuals who completed ¡PEDIR! training could self-select to join the TOT program, in which they would be trained on using the manual and program materials to bring back to their community and train others in their professional circle. Training participants who completed the program would become ¡PEDIR! Certified providers, forming a network of mental health and lay professionals equipped to work with at-risk individuals, as well as a network of trained peers to support one another and provide case consultation. The 6-month follow-up assessment also provided an opportunity to evaluate the progress of the training-of-trainers and the peer consultation network (number of additional providers successfully completing a ¡PEDIR! training delivered by a certified, trained program trainer; number of cases presented for consultation to certified trainees; and perceived benefits of the consult received, etc.). Community leaders were responsible for administering the follow-up assessment.

Step 5: Implement strategy

Approximately 41 mental health providers across disciplines (psychiatry, psychology, counseling, and psychiatric nursing) working in various settings (schools, hospitals, community-based health teams) providing mental health services to at-risk individuals in highly vulnerable communities in Lima, Peru, participated in the ¡PEDIR! training. Additionally, 34 university faculty and 25 university students participated in the ¡PEDIR! program curriculum development.

Training was developed in collaboration with the community leaders to address the key concerns raised during the focus groups, informed by current research on suicide assessment and intervention, and targeted: (1) preparing providers to engage with at-risk clients by increasing self-awareness of attitudes, biases, and assumptions regarding suicide; (2) evaluating relevant risk and protective factors; (3) conducting an effective risk assessment; (4) intervening with evidence-based strategies; and (5) reinforcing gains made in treatment. Primary outcomes assessed were increases in self-reported: (1) knowledge regarding warning signs, risk factors, and protective factors for youth suicide, and components of an effective risk assessment; (2) increased skills for engaging and treating at-risk youth; and (3) increased willingness to engage with individuals around their suicidal thoughts and feelings. Training was designed to be responsive to the level of prior mental health knowledge. For example, the training for students was 16 h over a four-day period and included key information on basic adolescent development and mental health, whereas the training for mental health professionals was a full-day 8 h workshop focused on suicide, based on their prior training in psychology and development. Lectures on core training content, role-play exercises of assessment and intervention strategies, and small group exercises examining case vignettes of at-risk individuals were developed as part of the training to reflect community-specific, culturally relevant issues and presenting problems. Role-play and case study exercise debriefs, lecture review, sharing of prior professional experience with at-risk individuals, and participant questions served as the basis for large group discussions.

The first round of training was delivered by the facilitator in partnership with a community leader, and other key community constituents were trained on the manual to deliver future sessions. A core group of university faculty was selected to work on curriculum development. A course syllabus was developed for the psychology and counseling program. University counseling center staff completed ¡PEDIR! and became certified trainers. A select group of mental health professionals who completed ¡PEDIR! also assumed the role of trainer.

Step 6: Evaluate outcomes

Questionnaires developed in Stage 4 eliciting participants’ self-reported improvements in attitude, knowledge and skill were the key mechanism used to determine if ¡PEDIR! training delivered the desired outcome. Acceptability was determined to be high, as demonstrated by the high rate of retention (98%), and participant self-reported ratings of the training as meeting their expectations, being satisfied with the training and finding the training to be useful for their professional development. Data from the questionnaires indicated that the training were effective at increasing all three targeted domains of knowledge, skill, and attitudes toward engaging with at-risk youth (p < 0.05) (details reported elsewhere) [28].

While ¡PEDIR! training was highly received, in further evaluation regarding the components of the training, community leaders believed that the training should be modified to allow for more time. More specifically, they determined that based on the qualitative responses of the participants, the training would be more effective of it were spread out over an additional day to allow for more reflection on the training content and discussion of the exercises, as well as more discussion of the cases they had encountered in the past and how applying the training content would have changed the treatment course of the patient. The manual was modified to reflect the changes desired by the community leaders.

Step 7: Determine next steps

To sustain and grow the impact of ¡PEDIR! training, certified trainees were identified to become program affiliates of the suicide prevention training and research program founded and directed by the training facilitator located in the United States. This international collaboration serves to support on-going community and professional development, provide access to resources to support the lay provider community, and act as a vehicle for consultation. As an unanticipated example, when the COVID-19 pandemic hit Peru, because this collaboration was already established, they were rapidly able to shift focus and develop public service announcements targeting mitigation strategies (i.e., hand-washing, mask-wearing), as well as mental well-being (i.e., quick exercises for managing COVID-related fear and anxiety, addressing feelings of isolation, hopelessness and helplessness). The PSAs were designed to be culturally relevant and were posted on the social media site of the University in Lima, Peru as well as many of the organizations of former certified ¡PEDIR! trainees.

Other important relationships were identified that could be established to support the growth and impact of ¡PEDIR! training. Leading universities were identified that were interested in developing curriculum on suicide prevention and intervention, on having their students complete ¡PEDIR! training, and on bringing ¡PEDIR! training to their community partners. Other established community mental health teams were also identified as important future participants.

One important next step identified concerns about how to bring ¡PEDIR! training to other highly vulnerable communities, such as those in rural communities outside the Capital, and to indigenous populations who do not speak Spanish but rather a dialect specific to the community, and where traditional ethnic customs and values are strongly adhered to and maintained in the community. In such cases, it was determined that an ECAPS “team” would be needed in which a local expert from the indigenous community could serve as a “Language and Values Ambassador” to facilitate and guide the 7-step process in a relevant and effective manner.

Discussion

We aimed to examine the effectiveness of the ECAPS Model at guiding the development of acceptable and feasible program of suicide prevention for a high-risk community in a low-resourced setting. We found that ECAPS provides a feasible, acceptable, and effective model for engaging and empowering communities in a collaborative process to develop, implement, sustain, and grow suicide prevention efforts. This is evidenced in the development and implementation of the ¡PEDIR! Program and its high degree of feasibility and acceptability in the community.

The increased capacity of the participants following the ¡PEDIR! Program in all three targeted domains of knowledge, skill, and attitudes toward engaging with at-risk youth directly addresses the key barrier in low-resourced settings of lack of human capital/infrastructure for mental healthcare provision. Participants strongly endorsed a lack of trained, specialized mental health professionals as a significant barrier to suicide prevention. Research supports this view noting a critical deficit of mental health professionals in LMICs [35, 36]. For example, the median number of psychiatrists per 100,000 population in LMIC is 0.05 whereas this number is 8.59 in high-income countries [37]. There is estimated to be a shortage of 1.18 million mental health workers in LMICs [38]. In Peru in particular, research demonstrates that for a population of nearly 30 million individuals, there were only 1.71 psychologists and 0.57 psychiatrists per 100 000 residents [37]. Therefore, an effective model of equipping current and future mental health professionals with specialized training to effectively engage with and treat at-risk individuals, such as the ¡PEDIR! Program, which directly addresses this key barrier is essential. The ¡PEDIR! Program effectively provides for the training of existing mental health professionals and for the identification of allied professionals, key constituents, and lay individuals in the community who can be trained to serve in a gatekeeper role where the mental health infrastructure does not exist. Building this type of community capacity is the heart of ECAPS model.

A key lesson gleaned from the implementation process of ECAPS in Peru is that no two suicide prevention programs should or will be the same. Further, given that the relevant social determinants of health related to suicide vary across communities, as do the risk and protective factors and the resources available for addressing suicide risk, no two trainings of the ¡PEDIR! Program will be the same. In this sense, the use of the ECAPS model provides for the development of a suicide prevention program that is not only individualized to each community but designed specifically around each community’s unique needs and assets.

The ¡PEDIR! Program is unique in that rather than representing a pre-determined evidence-based practice approach to suicide prevention that is simply adapted to a LRS by replacing standardized language with relevant cultural idioms of distress or explanatory models of illness, the content of the training program itself is driven by the nature, structure, and needs of each individual community. This ability to individualize and adapt the approach is a major strength. However, this process requires relationship building and establishing trust with local communities to get their buy-in for engaging in the process. This in-depth process may not be for everyone; those looking for a “quick fix” approach of implementing a pre-determined evidence-based intervention will likely have difficulty generating the motivation to engage in the process. However, as noted, the outcomes of such an approach will also be considerably less effective.

Conclusion

Further application of the ECAPS model in other low-resource settings has the potential to make a significant contribution to reducing suicide rates in these settings and contribute to a new generation of mental health and lay providers equipped with the necessary knowledge, skills, and attitudes to effectively assess, manage, and treat individuals struggling with suicidal thoughts and behaviors. The ¡PEDIR! Program is one such model and warrants further investigation in and of itself as a training model for lay providers in low-resource settings.

Funding

This funding was provided by Fordham University.

Declarations

Conflict of interest

The author has no conflicts of interest to declare.