Digital therapeutics in the hospital for suicide crisis - content and design recommendations from young people and hospital staff.

Objective: Hospital emergency departments lack the resources to adequately support young people who present for suicidal crisis. Digital therapeutics could fill this service gap by providing psychological support without creating additional burden on hospital staff. However, existing research on what is needed for successful integration of digital therapeutics in hospital settings is scant. Thus, this study sought to identify key considerations for implementing digital therapeutics to manage acute suicidal distress in hospitals. Method: Participants were 17 young people who recently presented at the hospital for suicide-related crisis, and 12 hospital staff who regularly interacted with young people experiencing mental ill-health in their day-to-day work. Interviews were conducted via videoconference. Framework analysis and reflexive thematic analysis were used to interpret the data obtained. Results: Qualitative insights were centred around three major themes: hospital-specific content, therapeutic content, and usability. Digital therapeutics were seen as a useful means for facilitating hospital-based assessment and treatment planning, and for conducting post-discharge check-ins. Therapeutic content should be focused on helping young people self-manage suicide-related distress while they wait for in-person services. Features to promote usability, such as the availability of customisable features and the use of inclusive design or language, should be considered in the design of digital therapeutics. Conclusions: Digital therapeutics in hospital settings need to benefit both patients and staff. Given the unique context of the hospital setting and acute nature of suicidal distress, creating specialty digital therapeutics may be more viable than integrating existing ones.

Assessing violence and injury prevention plans, strategies and indicators in eighteen Pacific Islands countries: an environmental scan.

Background: Similar to many other resource poor settings, due to competing priorities, injury is often neglected in the Pacific Islands despite being a prevalent cause of death and disability. This study identifies, and synthesises existing plans and strategies, and assesses progress against indicators for the prevention of violence and injury in 18 Pacific Islands nations to identify gaps and highlight opportunities. Methods: An environmental scan of known government repositories and Google Advanced was conducted to identify publicly available documents describing/evaluating national-level injury prevention strategies and plans in the Pacific Islands. Data were extracted on the strategy/plan, country, government department responsible, indicators and related progress. Findings: We identified 44 relevant documents. Most were published in more resourced countries (e.g., Fiji, Cook Islands) and described strategies/plans relating to traffic injury, injury from natural disaster and/or intimate partner violence. No strategies/plans to prevent injury mechanisms of drowning, falls, suffocation, burns, or electrocution were identified. Progress against only one indicator was reported for road traffic injury in the Commonwealth of the Northern Mariana Islands. Interpretation: This study suggests that there would be benefit in Pacific Islands nations to develop more robust data systems to assess progress against indicators of existing strategies and plans for traffic-injury, natural disaster and intimate partner violence. Development of strategies and implementation plans to address neglected injury areas such as drowning and falls which account for a significant burden of injury in the Pacific Islands is also recommended. Funding: This work was funded by the World Health Organization Regional Office for the Western Pacific (RG 221962).

Examining the Feasibility of Implementing Digital Mental Health Innovations Into Hospitals to Support Youth in Suicide Crisis: Interview Study With Young People and Health Professionals.

BACKGROUND: Hospitals are insufficiently resourced to appropriately support young people who present with suicidal crises. Digital mental health innovations have the potential to provide cost-effective models of care to address this service gap and improve care experiences for young people. However, little is currently known about whether digital innovations are feasible to integrate into complex hospital settings or how they should be introduced for sustainability. OBJECTIVE: This qualitative study explored the potential benefits, barriers, and collective action required for integrating digital therapeutics for the management of suicidal distress in youth into routine hospital practice. Addressing these knowledge gaps is a critical first step in designing digital innovations and implementation strategies that enable uptake and integration. METHODS: We conducted a series of semistructured interviews with young people who had presented to an Australian hospital for a suicide crisis in the previous 12 months and hospital staff who interacted with these young people. Participants were recruited from the community nationally via social media advertisements on the web. Interviews were conducted individually, and participants were reimbursed for their time. Using the Normalization Process Theory framework, we developed an interview guide to clarify the processes and conditions that influence whether and how an innovation becomes part of routine practice in complex health systems. RESULTS: Analysis of 29 interviews (n=17, 59% young people and n=12, 41% hospital staff) yielded 4 themes that were mapped onto 3 Normalization Process Theory constructs related to coherence building, cognitive participation, and collective action. Overall, digital innovations were seen as a beneficial complement to but not a substitute for in-person clinical services. The timing of delivery was important, with the agreement that digital therapeutics could be provided to patients while they were waiting to be assessed or shortly before discharge. Staff training to increase digital literacy was considered key to implementation, but there were mixed views on the level of staff assistance needed to support young people in engaging with digital innovations. Improving access to technological devices and internet connectivity, increasing staff motivation to facilitate the use of the digital therapeutic, and allowing patients autonomy over the use of the digital therapeutic were identified as other factors critical to integration. CONCLUSIONS: Integrating digital innovations into current models of patient care for young people presenting to hospital in acute suicide crises is challenging because of several existing resource, logistical, and technical barriers. Scoping the appropriateness of new innovations with relevant key stakeholders as early as possible in the development process should be prioritized as the best opportunity to preemptively identify and address barriers to implementation.

Co-design and Development of Implementation Strategies: Enhancing the PAX Good Behaviour Game in Australian Schools.

Effective implementation strategies are important for take-up of programs in schools. However, to date, few implementation strategies have been co-designed with teachers and support staff (including principals) in Australia. The aim of this study was to iteratively co-design multiple implementation strategies to enhance the delivery of mental health prevention program, PAX Good Behaviour Game, in New South Wales primary schools. The secondary aim was to evaluate the acceptability of the implementation strategies from the perspective of school staff. Twenty-nine educational staff (including principals) informed the co-design of the implementation strategies across three phases. Phase 1 involved a rapid review of the literature and stakeholder meetings to agree upon potential evidence-based strategies. Phase 2 involved focus group discussions with educational staff to co-design implementation strategies. Phase 3 involved semi-structured interviews with school staff to assess strategy acceptability after implementation at 6-months post-baseline. Data were analysed using deductive, framework analysis. The final co-designed intervention included nine implementation strategies accessible through a toolkit delivered to the school's leadership team. These strategies were deemed acceptable in school settings that experienced periods of both face-to-face and remote learning due to the changing COVID-19 situation in 2021. This paper contributes to the implementation literature by transparently reporting how educational staff-informed implementation strategies were iteratively co-designed. This will provide a roadmap for other researchers to co-design implementation strategies to further support the delivery of evidence-based prevention programs in schools.

Self-harm in 5-to-24 year olds: Retrospective examination of hospital presentations to emergency departments in New South Wales, Australia, 2012 to 2020.

There is some evidence that self-harm presentations in children and young people have increased over the past decade, yet there are few up-to-date studies examining these trends. This study aims to describe trends in the rates and severity of emergency department self-harm presentations for youth aged 5-24 years in New South Wales, Australia between 1 January 2012 and 31 December 2020. We analysed self-harm hospital presentations using join point analysis to compare quarterly growth in rates and urgency of presentation since 2012 by age group and sex. Binomial logistic modelling was used to identify risks for re-presentation for self-harm, including age group, sex, country of birth, mode of arrival, inpatient status, triage category, rurality, and socio-economic disadvantage. In total, 83,111 self-harm presentations for 51,181 persons were analysed. Overall rates of self-harm among those aged 5-24 years increased by 2.4% (p < .001) per quarter in females and 1.6% (p < .001) per quarter in males, with statistically significant average quarterly increases observed across all age groups. Overall and age-specific self-harm triage urgency rates increased statistically significantly for potentially serious, and potentially- and immediately life-threatening categories. A higher likelihood of re-presentation to any emergency department for self-harm was associated with younger age, female, residing in a regional area, arriving by ambulance, admitted as an in-patient, and a more severe index self-harm presentation. Hospital self-harm presentations have been growing steadily over the past decade, with the greatest growth in the youngest people. Understanding the reasons for these sustained upward trends is a priority for suicide prevention.

Self-harm in adolescence and risk of crash: a 13-year cohort study of novice drivers in New South Wales, Australia.

INTRODUCTION: Self-harm and suicide are leading causes of morbidity and death for young people, worldwide. Previous research has identified self-harm is a risk factor for vehicle crashes, however, there is a lack of long-term crash data post licensing that investigates this relationship. We aimed to determine whether adolescent self-harm persists as crash risk factor in adulthood. METHODS: We followed 20 806 newly licensed adolescent and young adult drivers in the DRIVE prospective cohort for 13 years to examine whether self-harm was a risk factor for vehicle crashes. The association between self-harm and crash was analysed using cumulative incidence curves investigating time to first crash and quantified using negative binominal regression models adjusted for driver demographics and conventional crash risk factors. RESULTS: Adolescents who reported self-harm at baseline were at increased risk of crashes 13 years later than those reporting no self-harm (relative risk (RR) 1.29: 95% CI 1.14 to 1.47). This risk remained after controlling for driver experience, demographic characteristics and known risk factors for crashes, including alcohol use and risk taking behaviour (RR 1.23: 95% CI 1.08 to 1.39). Sensation seeking had an additive effect on the association between self-harm and single-vehicle crashes (relative excess risk due to interaction 0.87: 95% CI 0.07 to 1.67), but not for other types of crashes. DISCUSSION: Our findings add to the growing body of evidence that self-harm during adolescence predicts a range of poorer health outcomes, including motor vehicle crash risks that warrant further investigation and consideration in road safety interventions. Complex interventions addressing self-harm in adolescence, as well as road safety and substance use, are critical for preventing health harming behaviours across the life course.

Strategies for Enhancing the Implementation of Universal Mental Health Prevention Programs in Schools: A Systematic Review.

A number of school-based mental health prevention programs have been found to be effective in research trials, but little is known about how to support implementation in real-life settings. To address this translational problem, this systematic review aims to identify effective strategies for enhancing the implementation of mental health prevention programs for children in schools. Four electronic databases were searched for empirical, peer-reviewed articles in English from January 2000 to October 2021 reporting the effects of implementation strategies for school-based universal mental health programs. Twenty-one articles were included in the narrative synthesis and assessed for quality using the Mixed Methods Appraisal Tool. Twenty-two strategies were found to be effective at improving program fidelity or adoption. The strategies with the strongest positive evidence base were those that involved monitoring and provision of feedback, engaging principals as program leaders, improving teachers' buy-in and organising school personnel implementation meetings. We recommend school-based practitioners trial strategies with positive findings from this review as part of their continuous quality improvement. This review highlights the pressing need for large-scale, randomised controlled trials to develop and trial more robust strategies to enhance adoption, as the five implementation studies found to measure adoption used qualitative methods limited by small samples sizes and case study designs.

A cluster randomised effectiveness-implementation trial of an intervention to increase the adoption of PAX Good Behaviour Game, a mental health prevention program, in Australian primary schools: Study protocol.

Introduction: Implementation of evidence-based programs in school settings can be challenging, undermining the benefits these programs deliver for children. The primary aim of this study is to assess whether an enhanced implementation intervention increases adoption of the PAX Good Behaviour Game in New South Wales (NSW) primary schools in Australia. A secondary outcome is to investigate the impact of the PAX Good Behaviour Game on children's mental health in the Australian context. Methods and analysis: The study uses a cluster randomised hybrid type 3 effectiveness-implementation design and will involve 40 NSW primary schools. Randomisation will occur at the school level. All NSW primary schools trained in the PAX Good Behaviour Game are eligible for participation. The intervention is a multicomponent implementation strategy that has been iteratively co-designed by our research team and local stakeholders. Intervention schools will have access to eight implementation support strategies in addition to the training received as usual delivery to build knowledge and skills. Research staff will assess implementation and effectiveness outcomes using self-report online surveys with teachers and support staff at baseline, 6-weeks, 6-months and 12-months follow up. Semi-structured interviews with teachers and support staff will be used to examine which implementation strategies worked for whom and under what conditions. Discussion: If successful, this study will highlight effective strategies schools or education departments can use internationally to improve their translation of evidence-based programs into routine practices. This will lead to better outcomes for children and young people.

"The real pandemic's been there forever": qualitative perspectives of domestic and family violence workforce in Australia during COVID-19.

BACKGROUND: In 2020, Australia, like most countries, introduced restrictions related to the global pandemic of coronavirus disease 2019 (COVID-19). Frontline services in the domestic and family violence (DFV) sector had to adapt and innovate to continue supporting clients who were experiencing and/or at risk of DFV. There is a need to understand from the perspective of those on the frontline how DFV service responses in different contexts impacted their working conditions and subsequent wellbeing, and what they want to see continued in 'the new normal' to inform future effective practices. We address this by reporting on findings from in-depth interviews conducted with practitioners and managers from the DFV sector in Australia. METHODS: Between July and September 2020 semi-structured interviews were conducted with 51 DFV practitioners and managers from a range of services and specialisations across legal, housing, health and social care services. The data was analysed using iterative thematic analysis. RESULTS: The most common service adaptations reported were shifting to outreach models of care, introducing infection control procedures and adopting telehealth/digital service delivery. Adjacent to these changes, participants described how these adaptations created implementation challenges including increased workload, maintaining quality and safety, and rising costs. Impacts on practitioners were largely attributed to the shift towards remote working with a collision in their work and home life and increased risk of vicarious trauma. Despite these challenges, most expressed a sense of achievement in how their service was responding to COVID-19, with several adaptations that practitioners and managers wanted to see continued in 'the new normal', including flexible working and wellbeing initiatives. CONCLUSIONS: The pandemic has amplified existing challenges for those experiencing DFV as well as those working on the frontline of DFV. Our findings point to the diversity in workforce experiences and has elucidated valuable lessons to shape future service delivery. Given the continuing impacts of the pandemic on DFV, this study provides timely insight and impetus to strengthen the implementation of remote working and telehealth/digital support across the DFV sector and to inform better supports for DFV workforce wellbeing in Australia and other contexts. TRIAL REGISTRATION: Not a clinical intervention.

Eating disorders in Australia: a commentary on the need to address stigma.

This commentary justifies the need for the Australian government to address stigma and shame in its effort to increase help-seeking by individuals with eating disorders from the intersectional perspective of a health consumer with a history of anorexia nervosa and a public health researcher. It does so in response to the government's planned 2019 investment of $110 million to subsidise eating disorders treatment services. The commentary identifies stigma and shame as the leading barrier to help-seeking among individuals with eating disorders. It then uses peer-reviewed evidence and analyses of popular press articles to show how media create stigma and shame through labelling and stereotyping individuals with eating disorders in a way that incites status loss and discrimination. The commentary justifies why Australia provides an interesting test case to trial the use of media regulations to address this international problem. It is recommended that the Australian government work with individuals with eating disorders to co-design a Mandatory Code of Conduct to guide media towards a more medicalised approach to representing the diverse spectrum of real individuals who experience eating disorders. This commentary is relevant to an international audience as it provides solutions to common challenges with media representations of individuals with eating disorders found in Western and Eastern contexts.