The PRINTEMPS study: protocol of a cluster-randomized controlled trial of the local promotion of a smartphone application and associated website for the prevention of suicidal behaviors in the adult general population in France

Users of e-Health tools for mental health and suicide primary prevention: description of their characteristics, usage, and satisfaction in the case of StopBlues

BACKGROUND

Thousands of mental health (MH) applications are currently available. Suicidal behavior prevention could benefit from such tools, but few have been evaluated. StopBlues (SB) is an app- and web-based intervention for suicide primary prevention for the French general population. Our objectives were to better understand who users of e-health tools for suicide prevention are by describing SB users' characteristics and their use of the tool, engagement and satisfaction along with the factors associated with the latter two.

METHODS

Age, gender, socioeconomic status (SES), and MH were collected from users who registered to SB between March 2018 and February 2020. MH was self-assessed with validated questionnaires on global MH, depression, anxiety and suicide risk. Use of SB was assessed through functionalities users interacted with (questionnaires, moodtrackers and/or safety plan). Engagement was calculated between date of registration and last interaction with those functionalities. Satisfaction was assessed through a dedicated survey between May 2019 to June 2020. Regression models studied the factors associated with satisfaction and duration of engagement.

OUTCOMES

10,792 people registered to SB during the study period. Two-thirds were women, mean age was was 38·5 years old (SD = 13·8), and 53·9 % lived in municipalities from the two highest SES quintiles. 47·8 % presented a risk of moderately severe or severe depression, and 27·2 % of severe anxiety. 23 % used the app for more than a day, with a mean duration engagement of 69 days (SD = 105). 96·4 % engaged at least once with either self-assessment questionnaires/moodtrackers or the safety plan, and 21·5 % interacted with both. 413 users completed the satisfaction survey and mean satisfaction was 61·6/100 (SD = 24·7).

INTERPRETATION

E-health tools for primary suicide prevention appear to be useful for users but close considerations to gender and age should be made when developing such tools.

FUNDING

French National Public Health Agency, Santé Publique France (grant 026/14).

Why and when should we cluster randomize?

A cluster randomized trial is defined as a randomized trial in which intact social units of individuals are randomized rather than individuals themselves. Outcomes are observed on individual participants within clusters (such as patients). Such a design allows assessing interventions targeting cluster-level participants (such as physicians), individual participants or both. Indeed, many interventions assessed in cluster randomized trials are actually complex ones, with distinct components targeting different levels. For a cluster-level intervention, cluster randomization is an obvious choice: the intervention is not divisible at the individual-level. For individual-level interventions, cluster randomization may nevertheless be suitable to prevent group contamination, for logistical reasons, to enhance participants' adherence, or when objectives pertain to the cluster level. An unacceptable reason for cluster randomization would be to avoid obtaining individual consent. Indeed, participants in cluster randomized trials have to be protected as in any type of trial design. Participants may be people from whom data are collected, but they may also be people who are intervened upon, and this includes both patients and physicians (for example, physicians receiving training interventions). Consent should be sought as soon as possible, although there may exist situations where participants may consent only for data collection, not for being exposed to the intervention (because, for instance, they cannot opt-out). There may even be situations where participants are not able to consent at all. In this latter situation a waiver of consent must be granted by a research ethics committee.

Defining the Characteristics of an e-Health Tool for Suicide Primary Prevention in the General Population: The StopBlues Case in France

With over one million deaths per year in the world, suicide is a major public health problem that could be significantly reduced by effective prevention programs. E-health tools are of particular interest for primary prevention as they can address a broad population including people unaware of their own risk and provide information and help without the fear of stigma. Our main objective was to define the overall characteristics of an e-health tool for suicide primary prevention in the French general population by defining the characteristics of the IT features; the content of the information delivered; the best way to structure it; and how it should be relayed and by whom. The research was carried out through a literature review and a co-construction phase with stakeholders. Four types of strategies may guide the construction of e-health tools for suicide primary prevention: education and awareness, (self-)screening, accessing support, and mental health coping. They should be accessible on different devices to reach the most users, and language and content should be adapted to the target population and to the issue being addressed. Finally, the tool should be consistent with ethical and quality best practices. The e-health tool StopBlues was developed following those recommendations.

Conditions for the Successful Integration of an eHealth Tool "StopBlues" Into Community-Based Interventions in France: Results From a Multiple Correspondence Analysis

Background

For over a decade, digital health has held promise for enabling broader access to health information, education, and services for the general population at a lower cost. However, recent studies have shown mixed results leading to a certain disappointment regarding the benefits of eHealth technologies. In this context, community-based health promotion represents an interesting and efficient conceptual framework that could help increase the adoption of digital health solutions and facilitate their evaluation.

Objective

To understand how the local implementation of the promotion of an eHealth tool, StopBlues (SB), aimed at preventing psychological distress and suicide, varied according to local contexts and if the implementation was related to the use of the tool.

Methods

The study was nested within a cluster-randomized controlled trial that was conducted to evaluate the effectiveness of the promotion, with before and after observation (NCT03565562). Data from questionnaires, observations, and institutional sources were collected in 27 localities where SB was implemented. A multiple correspondence analysis was performed to assess the relations between context, type of implementation and promotion, and use of the tool.

Results

Three distinct promotion patterns emerged according to the profiles of the localities that were associated with specific SB utilization rates. From highest to lowest utilization rates, they are listed as follows: the privileged urban localities, investing in health that implemented a high-intensity and digital promotion, demonstrating a greater capacity to take ownership of the project; the urban, but less privileged localities that, in spite of having relatively little experience in health policy implementation, managed to implement a traditional and high-intensity promotion; and the rural localities, with little experience in addressing health issues, that implemented low-intensity promotion but could not overcome the challenges associated with their local context.

Conclusions

These findings indicate the substantial influence of local context on the reception of digital tools. The urban and socioeconomic status profiles of the localities, along with their investment and pre-existing experience in health, appear to be critical for shaping the promotion and implementation of eHealth tools in terms of intensity and use of digital communication. The more digital channels used, the higher the utilization rates, ultimately leading to the overall success of the intervention.

International Registered Report Identifier (IRRID)

RR2-10.1186/s13063-020-04464-2

Suicide Prevention in Your Pocket: A Systematic Review of Ecological Momentary Interventions for the Management of Suicidal Thoughts and Behaviors

BACKGROUND

This study reviews the evidence on ecological momentary interventions (EMIs) for managing and preventing suicidal thoughts and behaviors.

METHODS

This review follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Its protocol was registered in the PROSPERO database. We conducted a systematic literature search of five databases: PubMed, EMBASE, Web of Science, PsycInfo, and Cochrane library. The most recent search date was 10 September 2021.

RESULTS

After screening and full-text review, 27 studies were included, totaling 19 different interventions. Many of the available interventions have not yet been clinically tested. Those that have undergone effectiveness evaluation (10 interventions) showed good rates of effectiveness and feasibility, with some exceptions. The most widely used intervention model is the safety plan, which allows the user to implement coping and distracting strategies in case of suicidal ideation.

CONCLUSIONS

Ecological momentary interventions provide certain advantages, such as their wide availability, versatility, and potential for customization. These interventions can be useful complements to traditional care, especially in situations in which face-to-face care is not possible. Evidence on the effectiveness of such interventions is still scarce. Furthermore, barriers limiting implementation in clinical practice remain. The constant advance of technology means that these interventions have great potential for improvement in the coming years.