« Previous | Contents | Next »
Listen
ANNEX 1 REVIEW OF NATIONAL STRATEGIES FOR SUICIDE PREVENTION
Introduction
Suicide is an issue of global concern, with between 500,000 and 1.2 million people worldwide dying by suicide each year (Hawton and Heeringen, 2000). Scotland is one of a number of countries to produce a national strategy on suicide prevention (Scottish Executive, 2002). The early implementation of this strategy is being evaluated and the work of the evaluation team includes a review of suicide prevention strategies across the world (especially England, Ireland, Australia, New Zealand, Finland, Norway, USA and Canada) to learn from other countries and to provide a basis for contrast and comparison.
The paper begins with a summary description of the strategies included in the review. It then considers the goals and priorities set out in these strategies before examining the processes and mechanisms described for implementation. The review concludes with brief observations and discussion of key points.
Methods
Definition of national suicide prevention strategy and selection criteria for review
A strategy for suicide prevention is taken to mean a set of integrated, multifaceted activities that are coordinated by government. A strategy aims to promote, support and link inter-sectoral programmes at local, regional and national levels.
A distinction has been drawn between strategies thus defined and programmes of prevention which involve one or more targeted activities, without coordination between the activities (Anderson and Jenkins, 2005). This review considers exclusively strategies which have been developed at national level. It was beyond the scope of this exercise to include strategies developed at regional / federal level. The review was restricted to strategies available in the English language.
Some countries may have suicide prevention goals and plans within their mental health policies without addressing suicide prevention in a separate policy. This review focuses only on those countries which articulated a separate suicide prevention strategy. It draws mainly on national strategy documents and selected literature that provides commentary on and, in a limited number of cases, evaluation of national approaches. The analysis that follows therefore is informed by what is stated in formal published policy documents. No attempt has been made to explore the extent to which or how policy statements have been implemented in practice. Nor is it possible, by simply reviewing published strategies, to ascertain in every case how strategies were developed, or to discern the relative influence of non-governmental organisations and community groups in this process.
Identification of national strategies for review
The main source for identification of strategies from other countries has been the Canadian Center for Suicide Prevention (Center for Suicide Prevention, 2004) which has an extensive bibliography of suicide prevention strategies and related literature. Searches of the literature published in the last 20 years were also conducted and an international expert from the Center for Suicide Prevention was consulted to guard against the omission of key strategies.
Process of analysis
The key areas that were examined in reviewing the ten strategise were the following:
- Origins and evolution of the strategy
- Scope: goals and objectives, the extent to which strategies make reference to evidence and to evaluation; the approach taken to suicidal behaviour and deliberate self-harm
- Structures within which the suicide prevention is located (table A1)
- Comprehensiveness including target setting for suicide prevention (table A2)
- Strategic components (table A3)
- Priority groups targeted (table A4)
- Mechanisms set out in strategies to support implementation (table A5).
Elements of a comprehensive suicide prevention strategy
The review uses the framework developed by the Center for Suicide Prevention ( CSP, 2004), based on the UN guidelines (1996). The core elements of a national strategy are as follows:
- Coordination and integration to promote cross-sectoral collaboration from governmental to community levels, undertaken by an identified coordinating body
- High-level political support for strategic aims, to lay the foundation for the strategy and its implementation. The guidelines suggest this is of particular importance in view of the need for cross cutting, interdepartmental support.
- A coherent conceptual framework that provides a model for understanding suicidal behaviour, to generate programmes of activity directed towards prevention and to foster research programmes
- Community involvement and engagement in formulating, implementing and evaluating programmes, recognising the important contribution of local / community based organisations and networks in implementation and review
- Objectives that are achievable and measurable, some of which may be expressed as targets for change
- Monitoring and evaluation to inform implementation and review of strategy.
Goals, strategic components and priority groups
The goals of national suicide prevention strategies can focus on:
- Universal, population level public health interventions e.g. to reduce risk conditions such as high unemployment, or to equip families, communities and organisations with skills and knowledge that promote mental health and well being and foster resilience. Core components include public awareness campaigns, media education, means restriction
- Selective interventions to address high risk sub groups within the general population e.g. to improve access to mental health care; to enhance the self esteem and coping capacity of high risk school students. Core components include training and access to services
- Indicated programmes targeted at groups at high risk e.g. pharmacological and behavioural treatments for people with specific mental illnesses. Core components here are access to services
(Beautrais, 2005; De Leo and Evans, 2004).
Suicide prevention interventions may therefore be targeted at a range of priority groups. In Scotland for example seven priority groups are identified: children, young people, people with mental health problems, those affected by suicide, people who abuse substances, people in prison / convicted of crime.
Strategic components of a strategy can encompass the following areas of activity: public awareness; media education; access to services; building community capacity; means restriction; training; and research and evaluation (De Leo and Evans, 2004).
Implementation mechanisms
There are a number of roles that an identified coordinating body can play in supporting implementation:
- to articulate how strategic goals are to be implemented through local and national structures and processes
- to provide leadership and direction in strategy development and implementation
- to facilitate vertical and horizontal coordination and linkages
- to maintain focus and commitment for the long term, including resource prioritisation
- to monitor trends and maintain surveillance of problems and issues.
(United Nations,1996; Anderson and Jenkins, 2005).
Key coordinating tasks include surveillance, research for example to identify risk and protective factors, programme development, programme evaluation to test effectiveness of interventions.
The UN Guidelines (1996) also suggest that effective national suicide prevention strategies require executive, financial and technical resources to carry out responsibilities effectively.
Results
The review has been able to identify ten strategies, which fit the definition given earlier: Australia, England, Finland, France, Ireland, New Zealand, Norway, Scotland, Sweden and USA.
Origins and comprehensiveness of national suicide prevention strategies
Table A1 summarises the origins, scope and broad content of the ten strategies. The table also describes the structures that support the strategy.
Table A1: Features of national suicide prevention strategies
Country and time span of national strategy | Origins | Scope and content | Structures to support implementation |
|---|
Australia National Youth Suicide Prevention Strategy 1997 Living is for Everyone ( LIFE) 2000 | Starting in 1994 with 10 year targets to achieve a 15% overall suicide reduction and 10% among people with schizophrenia, the strategy developed incrementally, leading to the National Youth Suicide Prevention strategy. This promoted cross sectoral evidence based responses in education and health services and incorporated social change programmes and measures to reduce access to suicide means. LIFE builds on the Youth Strategy, taking a whole systems / whole population approach to suicide prevention, supported by a 4 year budget of $48 m, with a particular focus on young people. LIFE, informed by extensive pilot work, provides a strategic framework for identifying priorities for national action to alleviate suicide, promote mental health and resilience. | LIFE identifies broad goals, action areas, target groups, partnerships and performance indicators. It presents data on patterns of suicide and suicidal behaviour. Objectives include targets to reduce the incidence of non fatal suicidal behaviour and to improve access to mental health care for those who present in hospital emergency departments. Self-harm is equated with attempted suicide and the only data cited on self-harm relate to hospitalisation episodes. | National Advisory Council on suicide prevention operates at Commonwealth level to advise Minister, to promote evidence based intervention and review national suicide prevention activities. State/territory specific pro-grammes are developed in partnership with national advisory bodies to maintain cohesion and coordination in line with national priorities and the evidence base |
England National Suicide Prevention Strategy for England 2002 | In 1994 targets aimed for a 15% reduction in overall suicide, 33% among people with severe mental illness, by 2000. Revised targets set in 2002 aim for a 20% suicide rate reduction by 2010, from a 1997 baseline. | The 2002 strategy sets out to be: comprehensive and cross sectoral; specific, built around identified actions that are practical and open to monitoring; evidence based (e.g. in determining high risk groups and in designing interventions); and subject to evaluation. The strategy sets goals, measurable objectives and detailed actions. Deliberate self-harm is regarded as a risk factor for suicide. The strategy includes an objective to reduce the number of suicides in the 12 months after an episode of deliberate self-harm. | The strategy is a core programme of the National Institute for Mental Health. It contains an implementation plan that builds on actions underway and links into wider policy context. Strategy is one of the core programmes of NIMHE which has responsibility for its implementation. It contains an implementation plan that builds on actions underway and links into wider policy context. Progress towards objectives is reviewed by a national strategy group and reported annually. |
Finland Suicide can be prevented 1993 | Finland's strategy began, uniquely, with a psychological autopsy of 1397 suicides. Findings from this, along with expert advice, informed the suicide prevention strategy, with identified target areas and responsibility for action | Finland was the first country to introduce a comprehensive national strategy for suicide prevention that works across sectors and at multiple levels. The strategy focuses on awareness raising and education, on building networks of support and on the effective treatment of depression. It is concerned with suicide and suicidal behaviour and stresses the need to identify signs of self-destructive behaviour in young people. | Shared responsibility for suicide prevention is central to the strategy, which provides a framework for implementation at regional and municipal level. Three consecutive phases of research, implementation and evaluation were overseen by an NGO with dedicated staff and central funding (1992 -96). |
France Strategy to address suicide 2000 | The national Programme for Suicide Prevention dates from 1996/7, followed by an action plan for 2000-5. In 2003, the Health Dept issued a series of public health reports for consultation, including one on suicide. | This proposes a suicide reduction target of 20% in the general population, halving suicides among young people and men over 75 and reducing rates among prisoners. Key priorities for action cover: improving the identification of risk, including depression; enhancing access to services; and reducing access to and lethality of means. The strategy does not describe structures or processes for implementation. | Government requested the Minster for Health & Disability to develop a suicide prevention action plan for 2000 - 05. Suicide prevention is a stated public health policy priority. |
Ireland Report of the National Task Force on Suicide 1998 Reach Out. National Strategy for Action on Suicide Prevention 2005 | Analysis of suicide trends in 1996 led to the production of the strategy in 1998. Building on the work of the National Task Force and local developments to address suicide, the action plan was developed through wide-ranging consultation, informed by reviews of evidence and best practice. | The 3 strands of work proposed encompass: public health measures; good quality health services; and comprehensive responsive community based services and resources. The strategy offers over 100 recommendations relating to: health service provision; training and awareness of professionals; prevention; interventions to identify, assess and treat mental illness; support for those affected by the aftermath of suicide; and research and evaluation. 'Parasuicide' is used to signify both a 'cry for help' and a "failed suicide". It also refers to those who deliberately injure themselves 'in a suicidal manner'. Data presented on trends in parasuicide and associated costs relate to self poisoning only. The Action Plan covers 4 levels of activity: population approaches, targeted approaches, responding to suicide and research and information. | A National Task Force produced recommendations that informed the national strategy. A National Office for Suicide Prevention is to be established to drive implementation forward and is expected to develop programmes to address key strategic priorities. A Steering Group will guide its work, and a national representative forum will encourage information sharing. The NOSP will produce an annual report of progress. |
New Zealand In our Hands: New Zealand youth Suicide Prevention Strategy 1998 | The Youth Suicide Prevention Strategy grew out of extensive stakeholder involvement and a review of the evidence base. In Jan 2005, the New Zealand Government announced that the strategy will be broadened to all age groups. A stock take of activity since 1998 and a review of the evidence base for suicide prevention have been produced. | There is a general population strategy and one focusing on Maori communities. Goals comprise: promoting well being; early identification and help; crisis support and treatment; support after suicide; and information and research. The strategy offers examples of evidence based interventions relating to: parenting programmes; the detection and treatment of depression; improvement in health services management of suicidal patients; the reduction of social and economic inequalities e.g. labour market disadvantage and employability. Self-harm is equated with attempted suicide. | The strategy for youth suicide prevention proposed a coordinated, inter-agency approach supported by national bodies to undertake an extensive range of programmes. |
Norway The National Plan for Suicide Prevention 1994 | National Government Departments identified suicide as an issue of shared concern. | The plan focuses on: research; training and professional development; piloting interventions and service models to raise awareness; improved access to help; and the promotion of intersectoral collaboration. There is less attention to universal prevention and promotion factors. The strategy does not make clear distinctions between suicide and suicidal behaviour. People who have 'shown suicidal behaviour' are regarded as future suicide risks. | The National Plan for Suicide Preventions encourages a cross government approach, coordinated by the Board of Health, with a budget for implementation. |
Scotland Choose Life: A National Strategy and Action Plan to Prevent Suicide in Scotland 2002 | Choose Life was created and is intended to be implemented collaboratively. It grew out of concerns about trend in suicide among young men and developed against backdrop of wider policy development on public mental health. | The 10 year strategy aims to reduce suicide by 20% by 2013, with a budget of 12m for the first 3 years, for local and national actions. The strategy includes objectives and milestones to assess progress. The focus is on building capacity, commitment and leadership and utilising existing structures and processes to ensure sustainability. The relationship between suicide and suicidal behaviour is considered in some detail, to distinguishing between deliberate self-harm ( DSH) and an intent to kill oneself but also recognising DSH as a risk factor for suicide. | Choose Life was issued as a cross departmental government policy. A National Implementation Support Team was established to work with local areas and national and local bodies on programme development and on data gathering and evaluation. |
Sweden Support in Suicidal Crises. The Swedish National Programme to Develop Suicide Prevention 1995 | National cross sectoral collaboration led to a programme on suicide prevention. | The strategy sets objectives and gives guidelines for suicide prevention. It stresses the importance of marrying an understanding of the evidence base with an understanding of the cultural / philosophical significance of suicide. Three levels of intervention are described: measures to enhance individual coping capacities; measures to minimise or reduce the impact of risk conditions; and interventions to prevent suicide including reduced access to means. The focus of the strategy is on suicide and attempted suicide. Suicide is regarded as 'inwardly directed violence'. | A National Council for Suicide Prevention which encourages education, research and development. The strategy details tasks and assigns responsibility for these to named bodies but does not explain how the strategic programme is to be coordinated or resourced. |
USA National Strategy for Suicide Prevention 2001 | The strategy emerged from concern about suicide as a public health issue, from international attention to suicide prevention by WHO and UN and from grass roots networks which lobbied for the development of a US strategy. Goals and objectives for suicide prevention were subject to consultation and discussion with clinicians, scientists, professionals and the public up to 2000. | The US strategy is a framework to strengthen collaboration, guide priorities and support States, communities and tribes in developing their own suicide prevention plans. Informed by analysis of risk and protective factors for suicide and reviews of international experience of developing suicide prevention strategies, the strategy sets out goals that encompass: building awareness and support for suicide prevention, reducing stigma associated with particular conditions and services, public health measures to reduce access to means of suicide, training and professional development, media reporting, access to community resources and specialist services and improved surveillance. Suicide attempts are viewed as 'self destructive behaviour'. | The strategy is intended as a framework to encourage, inform and motivate key stakeholders and as a model to guide State strategies in using the evidence base. |
Table A2 examines the comprehensiveness of national strategies, using the framework developed by the Center for Suicide Prevention ( CSP, 2004), summarised above.
There is considerable convergence among those countries which produced a strategy after 1996, as these tend to make reference to the UN guidelines as an important source document.
Targets
Jenkins and Singh (2000) note that target setting can be an important mechanism to promote action. Targets can influence the activities of government, public services and professional education and training bodies. Targets can also impact on the activities and priorities of a wide range of agencies in the community, voluntary and private sectors which can make a contribution to strategic suicide prevention objectives. In addition, targets can help set an explicit framework in which the responsibility for achievement of objectives does not rest with individual clinicians/practitioners alone but with all sectors.
As shown in table A2, several countries do not set identified targets in their strategy. Ireland's strategy, for example, contains wide-ranging recommendations recently supplemented by an implementation plan but no targets. Sweden has clearly defined objectives, but these are not developed into targets for implementation.
Evaluation and evidence
In general 'monitoring and evaluation' tend to refer to the evaluation of interventions that are the means of delivering the objectives and not to the evaluation of the strategy itself. Notable exceptions are Norway and Scotland. Australia has undertaken a comprehensive programme of research and development to inform the planning and implementation of interventions. This work is reported in detail in supporting documents that accompany the strategy. Finland built its strategy on extensive research into the scale and nature of the problems associated with suicide and suicidal behaviour. The evaluation of the strategy that was subsequently implemented was, however, very limited. Although the implementation process was described as 'learning by doing' the external evaluation was undertaken retrospectively and this limited its value, as did the adherence to a psychiatric / medical paradigm.
Key findings from the evaluation of the Finnish strategy include the following:
- The strategy had highlighted problems and complexities of suicide in Finnish society
- Although rates of suicide had decreased it was not possible to attribute this to the strategy
- There were gaps e.g. in projects that addressed suicide among older people and access to means of suicide
- The strategy had not fostered the level of professional and political commitment required for sustainability
- Projects were insufficiently integrated with mainstream health care systems
- The planning of the implementation and evaluation phase did not allow for adequate evaluation of effectiveness.
Table A2: Comprehensiveness of national suicide prevention strategies against CSP framework
Country | Date of publication | Gov policy | Model | Coordinating body | Community engagement | Clear objectives/targets | Monitoring & evaluation |
|---|
Australia | 1997*
2000 | +
+ | +
+ | +
+ | +
+ | +
+ | +
+ |
England | 2002 | + | + | + | + | + | + |
Finland | 1993 | + | + | + | + | + | + |
France | 1999 | + | - | - | - | + | + |
Ireland | 1998, 2005 | + | + | + | + | Clear objectives, no targets | + |
New Zealand | 1998** | + | _ | _ | + | 5 goals relating to levels of suicide prevention, each with objectives | + |
Norway | 1994 | + | - | + | + | + | + |
Scotland | 2002 | + | + | + | + | + | + |
Sweden | 1995 | + | + | - | + | Clear objectives, no targets | |
New Zealand | 1998** | + | _ | _ | + | 5 goals relating to levels of suicide prevention, each with objectives | + |
USA | 2001 | + | + | - | + | 11 goals with objectives and targets for 2005 | + |
Key
+ indicates that the strategy includes this element
- indicates that the strategy does not include this element
* Australia: earlier strategy covered young people only, the later strategy covers the whole population
**New Zealand strategy currently covers young people only
Gov Policy indicates that the strategy is a formal statement of policy issued by Government
Model indicates the presence or absence of a model for understanding suicidal behaviour
It is common for strategies to provide an analysis of trends and patterns in suicide and suicidal behaviour and many also compare national trends with more global or international trends. Trend data are only one source of intelligence considered in setting goals and identifying priority groups (see below). The other two principal sources are consultation with stakeholder groups and analysis of evidence for effective interventions to reduce suicide.
Goals, strategic components and priority groups
All of the strategies reviewed identify goals that relate to each of the three levels of intervention: universal, selective and targeted. Table A3 summarises the main components described in the strategies of different countries (De Leo and Evans, 2004). Almost every country makes reference to the full range of suicide prevention components. However, the French and Norwegian strategies do not make specific provision for public awareness or media education. Norway, and to some extent Finland, do not give priority to tackling access to the means of suicide.
Table A4 maps out the priority groups identified in each strategy. There is much similarity in the priority groups identified with the exception of those countries where young people were the main priority initially. The French strategy does not include those with substance misuse problems. Norway's strategy makes no reference to prisoners / those involved with the criminal justice system nor does it refer to those affected by suicide as key target groups, although it does make specific mention of the high risk of suicide among medical practitioners. England also refers to high risk occupations, including farmers and medical professionals. Several strategies, including those of Australia, New Zealand and England, make reference to particular ethnic groups. While young people receive considerable attention as one (if not the main) priority, Norway, Ireland and England also regard older people as a risk group. England, Ireland and Scotland make explicit reference to social exclusion and socio-economic disadvantage.
Implementation mechanisms
National strategies vary in the extent to which they give an indication of the approach and methods of implementation that will be utilised to achieve their goals. Table A5 reviews the implementation approaches described in national strategies.
In one set of strategies, including those of Australia, England, Finland, Norway and Scotland, the mechanisms to ensure effective coordination are relatively clearly identified in an implementation plan with identified resources. Scotland's strategy, gives more detail than others of the level of financial resource available locally and nationally and indicates how support is to be provided for capacity building and implementation. Ireland's recent implementation plan identifies mechanisms for coordination and indicates that unspecified levels of additional funding will become available for implementation.
A second set of strategies, including those for France, Sweden, New Zealand and USA, does not include an implementation plan. The New Zealand strategy anticipates the development of an implementation plan.
Table A3: Strategic components of national suicide prevention strategies
Country | Public awareness | Media education | Access to services | Building community capacity | Means restriction | Training | Research and evaluation |
|---|
Australia
1997
2000 |
+
+
|
+
+
|
+
+
|
+
+
|
+
+
|
+
+
|
+
+
|
England | + | + | + | + | + | + | + |
Finland | + | + | + | + | (+) | + | + |
France | - | - | + | - | + | + | + |
Ireland | + | + | + | + | + | + | + |
Norway | - | - | + | + | - | + | + |
Scotland | + | + | + | + | + | + | + |
Sweden | + | + | + | + | + | + | + |
New Zealand | + | + | + | + | + | + | + |
USA | + | + | + | + | + | + | + |
AfterDe Leo and Evans, 2004
Key
+ indicates that the strategy covers this component
(+) indicates that the strategy makes limited reference to this component
- indicates that this component is not included in the strategy
Table A4: Priority groups in national suicide prevention strategies
Country | Children | Young people | Older people | People with mental health problems | People who attempt suicide | People affected by suicide | People who abuse substances | People in prison/ convicted of crime | Occupational groups | Ethnic groups | Socially excluded/ disadvantaged | Other |
|---|
Australia | + | + | - | + | + | + | + | + | - | + | - | |
England | + | + | + | + | + | + | + | + | + | + | + | 1,2 |
Finland | + | + | - | + | + | + | + | + | - | - | - | - |
France | - | + | - | + | + | + | - | - | - | - | - | - |
Ireland | + | + | + | + | + | + | + | + | + | - | + | - |
Norway | - | + | - | + | + | - | + | - | + | - | - | - |
Scotland | + | + | - | + | + | + | + | + | - | - | + | 3,4 |
Sweden | + | + | - | + | + | + | + | + | - | + | - | 2,5 |
New Zealand | + | + | - | - | - | - | - | - | - | - | - | - |
USA | + | + | + | + | + | + | + | + | + | - | - | - |
Key
+ identified as a priority setting / group in the strategy
- not included as a priority setting / group in the strategy
Other groups: 1. Expectant mothers; 2. Survivors of abuse; 3. Recently bereaved; 4. People living in rural / isolated communities; 5. Those with HIV/ AIDS
Table A5: Implementation approaches in national suicide prevention strategies
Country | Surveillance | Research | Programme development | Evaluation: programmes of action | Evaluation: strategy | Resources identified
(exec/ technical/ financial) |
|---|
Australia | + | + | + | + | + | + |
England | + | + | + | + | - | + |
Finland | + | + | + | + | + | + |
France | - | - | - | - | - | - |
Ireland | + | + | + | + | - | - |
Norway | + | + | + | + | + | + |
Scotland | + | + | + | + | + | + |
Sweden | - | - | - | - | - | - |
New Zealand | - | - | - | - | - | - |
USA | - | - | - | - | - | - |
Key
+ indicates that the strategy adopts this approach
- indicates that the strategy does not adopt this approach
Discussion and conclusions
Inevitably there are limitations associated with an exercise that has only focused on what is contained in published national strategy documents. Expert sources (Richard Ramsay, personal communication) suggest that the pace and process of implementation in certain other countries provide important points of comparison with Scotland and potential learning opportunities. However, this would not be achievable without more proactive investigation to explore how the strategic intentions set out in the documents reviewed above have, and have not, been followed through to implementation. In addition, there are likely to be regional/federal strategies (e.g. Nuremberg) which may be of potential interest to and sources of learning for Scotland, but these were beyond the scope of this review.
The evidence of a growing commitment to national strategic approaches to suicide prevention is fuelled by a growing recognition of suicide as a major public health issue which has complex causes and which requires coordinated multi sectoral and long term interventions (Anderson and Jenkins, 2005).
Despite the limitations of the review and the necessary qualifications attached to what can be read into strategy documents, several points emerge. The strategies reviewed have been informed by and drawn heavily on a common set of international guidelines and a growing body of research on the risk factors and causal pathways for suicide and suicidal behaviour. Strategies therefore tend to have many similarities in terms of broad goals and priorities. However there are also striking divergences.
Firstly is the variability in the definitions used in and the parameters set by national strategies in tackling the common issue of suicide. The UN guidelines ( UN,1996) regard suicidal behaviour and the conditions antecedent to it as the appropriate focus for preventive actions. This is taken to include completed suicide and attempted suicide/parasuicide, as well as those 'conditions, states and disorders which herald or predispose self destructive behaviour'. The review indicates (table A1) that the relationship between suicide, attempted suicide and deliberate self-harming behaviour is understood in a number of different ways. Scotland is unusual in that it acknowledges that, although there is a degree of overlap between deliberate self-harming behaviour and attempted suicide, the two phenomena are to a large extent discrete and distinctive. Other countries tend to regard self-harming behaviour as a marker for increased risk of suicide only. Where data are provided on rates or trends in self-harm or attempted suicide these tend to relate to hospitalisation following episodes of self poisoning.
Secondly, there is very limited attention to the evaluation of the implementation of national strategies (table A2). Scotland stands out in this regard and is in a good position to ensure that anticipated outcomes and impacts are well articulated for the purposes of evaluation. This would make it possible to go beyond the surveillance of trends in suicide, to evaluate intermediate and long term outcomes related to suicide and suicidal behaviour.
Thirdly, national strategies represent a response to an identified problem - in this instance suicide - which is considered to merit attention and intervention by government. The triggers that led to the development of national strategies for suicide prevention are broadly similar in most countries (table A1): evidence of worrying trends in suicide rates; pressures from stakeholders at community level to address this; increasing knowledge and understanding of the causes and contributory factors and evidence of effective interventions; examples of what is happening in other countries to tackle suicide; and cultural and philosophical concerns about the meaning of suicide as part of the human condition. What may vary is the relative weight given to these factors in different countries.
All 10 strategies indicate the involvement of stakeholders to varying degrees in formulating objectives and identifying priorities (table A4). While there is considerable similarity in the broad content of national suicide prevention strategies, which have been influenced by international guidelines, there is greater disparity with regards to the focusing of priorities. The identification of priority groups is likely to have been influenced by particular features of national populations and / or the specific epidemiological features of suicide in the country and by the interventions of stakeholders and grass roots organisations.
A fifth differentiating feature can be found in the approaches taken to, and mechanisms for, implementation (table A5). Some strategies scarcely go beyond the stating of objectives and do not address implementation. Others pay this considerable heed and provide detailed plans for action. From the information available, Scotland seems to be well placed in this regard in having an identified budget, a designated team to coordinate and support development and a process evaluation.
Developing more robust evidence to support suicide prevention strategies and programmes is one of the central challenges for the 21 st century (Beautrais, 2005)
It has been remarked that, while enthusiasm for suicide prevention activities is increasing throughout the world, there is as yet little indication that national suicide prevention strategies have a positive impact on death by suicide (De Leo and Evans, 2004). To assess the impact of national suicide prevention strategies, these authors conducted an analysis of trends in suicide rates in four countries (Finland, Norway, Sweden and Australia) where sufficient pre and post implementation data were available. This study investigated suicide rates five years before and five years after implementation. There was promising, though inconclusive, evidence that the Finnish national strategy was associated with a reduction in suicide rates in both men and women of all ages. However, in each of the other three countries suicide rates increased following implementation. It is suggested that longer time frames are required, first to offset the wide variations in suicide rates observable in a five year period and, second, to allow for the full implementation of strategies which tend to have multiple components.
The dearth of evidence on the effectiveness, including the cost effectiveness, of national suicide prevention strategies on suicide rates makes it all the more important to gain a better understanding of the means by which strategies are being or can be translated into effective interventions and actions (Anderson and Jenkins, 2005). Others (Beautrais et al, 2005) urge caution in extrapolating from as yet limited knowledge about risk and resiliency factors for suicidal behaviour to formulate programmes and interventions.
This review of national strategies has thrown up some interesting points of comparison that provide a context within which to locate Scotland's Choose Life policy. It has also highlighted aspects of other national strategies that would that merit further more proactive investigation, beyond documentary analysis.
References
Anderson M and Jenkins R The Challenge of Suicide Prevention. An Overview of National Strategies. Disease Management Health Outcomes 13:4, 245 -253.
Beautrais A L (2005) National Strategies for the Reduction and Prevention of Suicide. Crisis, 26.1: 1-3
Beautrais A L, Collings SCD, Ehrhardt P and Henare K (2005 ) Suicide Prevention. A review of the evidence of risk and protective factors and points of effective intervention. Wellington, Ministry of Health.
Center for Suicide Prevention (2004) A Summary of National State and Provincial Strategies for Prevention of Suicide. Calgary, CSP.
De Leo D and Evans R (2004) International Suicide Rates and Prevention Strategies. Gottingen, Hogrefe and Huber.
Hawton K and Heeringen K (editors) (2000). The international book of suicide and attempted suicide. Chichester, John Wiley and Sons Ltd.
Jenkins R and Singh B (2000) General Population Strategies of Suicide Prevention. In Hawton K and van Heeringen K (eds)
Taylor SJ, Kingdon D and Jenkins R (1997) How are nations trying to prevent suicide? An analysis of national suicide prevention strategies. Acta Psychiatrica Scandinavia95, 457 - 463.
Goldsmith SK et al (2002) Reducing Suicide. A National Imperative. Washington, Institute of Medicine, The National Academies Press.
United Nations (1996) Prevention of Suicide. Guidelines for the Formulation and Implementation of National Strategies. New York, United Nations.
UN/ WHO Calgary Meeting (undated) Forming National Suicide Prevention Strategies: A Report of the UN/ WHO Calgary Meeting.
National Suicide Prevention Strategies
Department of Health (2002) National Suicide Prevention Strategy for England. London, Department of Health.
Department of Health and Children (1998) Report of the National Task Force on Suicide. Dublin, Government of Ireland.
Commonwealth Department of Health and Family Services (1997 ). Youth Suicide in Australia: The National Youth Suicide Prevention Strategy. Canberra, Australian Government Publishing Service.
Commonwealth Department of Health and Aged Care (2000) Life Is For Everyone. A Framework for prevention of suicide and self -harm in Australia. Canberra,
Commonwealth Department of Health and Aged Care.
Health Service Executive (2005) Reach Out. National Strategy for Action on Suicide Prevention.2005 - 2014. Dublin, Department of Health and Children.
Ministry of Health (1998) In our Hands: New Zealand Youth Suicide Prevention Strategy. Wellington,
Norwegian Board of Health (1994) The National Plan for Suicide Prevention 1994- 98. Oslo Norway.
National Council for Suicide Prevention, The National Board of Health and Welfare. The National Institute for Public Health and the Centre for Suicide Research and Prevention. (1995) Support in Suicidal Crises. The Swedish National Programme to Develop Suicide Prevention. Stockholm, National Institute for Public Health.
National Research and Development Centre for Welfare and Health (1993 ) Suicide Can be Prevented: Fundamentals of a Target and Action Strategy. Helsinki.
Scottish Executive (2002) Choose Life: a National Strategy and Action Plan to Prevent Suicide in Scotland. Edinburgh, Scottish Executive.
Strategie Francaise d'actions face au suicide 2000/5. www.infosuicide.org/fpronat.htm
US Department of Health and Human Services, Public Health Services. (2001) National Strategy for Suicide Prevention: Goals and Objectives for Action. Rockville MD, Public Health Service.
« Previous | Contents | Next »