Hanlon Et Al. (2022)

13697625, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hex.13661 by University of Hong Kong, Wiley Online Library on [29/12/2022].
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Received: 3 August 2022 | Revised: 6 October 2022 | Accepted: 25 October 2022
DOI: 10.1111/hex.13661
REVIEW ARTICLE
Evaluating the role and effectiveness of co‐produced

community‐based mental health interventions that aim
to reduce suicide among adults: A systematic review
Claire A. Hanlon MSc, PhD Student | David McIlroy PhD, Reader |

Helen Poole PhD, Professor | Jennifer Chopra PhD, Programme Leader Psychology |
Pooja Saini PhD, Reader
School of Psychology, Faculty of Health,

Liverpool John Moores University, Abstract
Liverpool, UK
Background: Suicide is a major public health risk requiring targeted suicide
Correspondence prevention interventions. The principles of co‐production are compatible with
Claire A. Hanlon, MSc, PhD Student, School of tailoring suicide prevention interventions to meet an individual's needs.
Psychology, Faculty of Health, Liverpool John
Moores University, Liverpool L3 3AF, UK. Aims: This review aimed to evaluate the role and effectiveness of co‐produced
Email: [email protected] community‐based suicide prevention interventions among adults.
Methods: Four electronic databases (PsycInfo, CINAHL, MEDLINE and web of
science) were systematically searched. A narrative synthesis was conducted.
Results: From 590 papers identified through searches, 14 fulfilled the inclusion
criteria. Most included studies elicited the views and perspectives of stakeholders in
a process of co‐design/co‐creation of community‐based suicide prevention
interventions.
Conclusion: Stakeholder involvement in the creation of community‐based suicide
prevention interventions may improve engagement and give voice to those
experiencing suicidal crisis. However, there is limited evaluation extending beyond
the design of these interventions. Further research is needed to evaluate the long‐
term outcomes of co‐produced community‐based suicide prevention interventions.
Patient and Public Involvement: This paper is a systematic review and did not
directly involve patients and/or the public. However, the findings incorporate the
views and perspectives of stakeholders as reported within the studies included in
this review, and the findings may inform the future involvement of stakeholders in
the design, development and delivery of community‐based suicide prevention
interventions for adults.
KEYWORDS
adults mental health, community‐based, co‐production, suicide, suicide prevention, systematic
review
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2022 The Authors. Health Expectations published by John Wiley & Sons Ltd.
Health Expectations. 2022;1–23. wileyonlinelibrary.com/journal/hex | 1

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2 | HANLON ET AL.
1 | INTRODUCTION The principles of co‐production are congruent with tailoring

suicide prevention interventions to suit the needs of individual
Co‐production is advocated within mental health policy and has service users and are aligned to recovery‐orientated services that
garnered increasing attention.1–3 This is highlighted within health emphasize individualized care and recognize the value of experiential
care initiatives including person‐centred care,4 the ‘Five Year Forward knowledge.6,7,28 Research is emerging that supports implementation
View for Mental Health’ policy strategy5 and more recently ‘The of co‐produced mental health service provision. For example, studies
Community Mental Health Framework for Adults and Older Adults— evaluating the impact of recovery colleges featuring co‐
Support, Care and Treatment. Part 1 & 2’.6,7 Within a co‐ production have reported positive outcomes upon service‐user
production framework, multiple stakeholders work in collaboration, well‐being such as improved self‐esteem or confidence,29 improved
including commissioners, service providers and service users.8,9 employment opportunities30 and reduced use of mental health
Emphasis is placed upon shared decision‐making and information services.31 Additionally, applying co‐production to tailor delivery of
2
exchange within a mutually equitable relationship. Subsequently, mental health services such as the Improving Access to Psychological
equal value is placed upon contributions by service users, and service Therapies to improve reach among black and minority ethnic
2,3
providers and professionals. communities has shown increased accessibility and retention.32
It is argued that co‐production produces meaningful knowledge Further, Pocobello et al.33 reported a 63.2% reduction in hospitaliza-
9,10
within the context to which it is to be applied. This creates tions and a 39% decrease in psychiatric medication use or withdrawal
services that are more contextually specific, promoting engagement among service users of an experimental co‐produced mental health
and bridging the translational gap between research evidence service versus traditional mental health services. Findings such as
production and real‐world implementation.9,11 Relatedly, co‐ these are encouraging; however, qualitative findings pervade this
production improves quality of care,3,12 having considered service field and there remains a paucity of quantitative research assessing
user needs and priorities during the co‐production process1,13 leading the impact of co‐production within mental health service provision,34
to cost‐efficient and cost‐effective services.14 even less so in relation to suicide prevention. While studies focusing
Despite the highlighted benefits of co‐production, several upon the preventative aspect of co‐produced mental health services
limitations have been identified. There remains a lack of consensus assert that they prevent service user mental health from reaching
in how co‐production is defined, leading to interchangeable language crisis point,34 validated assessment of this impact is lacking.
used to describe co‐production processes.2,13,15,16 For example, As highlighted, co‐production does have its limitations, which
undefined collaborative roles have led to a plethora of collaborative need to be mitigated for the potential of co‐production in suicide
working activities marketed under a co‐production umbrella including prevention to be fully embraced. Key to furthering understanding of
co‐creation and co‐design.13,17,18 This ‘one size fits all’ approach is the role of co‐production within suicide prevention relies upon
attributed to different interpretations in how co‐production is understanding the language used to define co‐production; evaluating
operationalized within policy, knowledge creation and subsequently how and to what extent service providers and service users
implemented in practice within service delivery.2,19,20 There is a contribute to the co‐produced service and how information is
paucity of evaluation considering the extent to which co‐productive synthesized, and outcomes are assessed. Therefore, this review aims
20–22
approaches cultivate meaningful outcomes and whether positive to evaluate the role and effectiveness of co‐produced, community‐
outcomes associated with co‐production are sustained over time.23 based suicide prevention interventions for adults that aim to reduce
Further, reluctance to relinquish professional roles and responsibili- suicide to:
ties, such as those held by researchers or practitioners, may lead to a
power imbalance that could threaten the integrity of the mutually 1. Understand how co‐production is defined and operationalized.
9,12
equitable relationship. 2. Examine evidence for the role of co‐production in these
Mental health services have striven to harness the innovative interventions.
and transformative potential of co‐production in a quest to improve 3. Identify and evaluate co‐production‐related outcomes associated
service user inclusivity in decision‐making, and service delivery and with these interventions.
1
experience. Suicide is a major public health problem, accounting for 4. Identify and evaluate intervention components associated with a
over 700,000 deaths worldwide.24 Help‐seeking remains a significant reduction in suicide‐related outcomes.
barrier for those at risk of suicide, with fewer than one‐third of
individuals seeking help for their mental health.25 The reasons why
individuals experiencing suicidal thoughts and behaviours do not seek 2 | METHODS
help from mental health services vary but include high self‐reliance, a
low perceived need for treatment and stigmatizing attitudes towards The protocol for this review was registered on the University of York,
suicide and/or mental health problems and seeking professional Systematic Review database PROSPERO (CRD42020221564).35 The
26
help. In recognition of such barriers, there has been a call for research questions and inclusion and exclusion criteria were
suicide prevention interventions to be tailored to improve reach and generated using the patient/problem or population, intervention,
increase effectiveness.27 comparator and outcome (PICO) framework.
HANLON ET AL. | 3
2.1 | Eligibility criteria 2.3 | Search terms
Studies were eligible for inclusion if they fulfilled the following Scoping of the literature was undertaken in the development of the
criteria: search terms exploring the extent of co‐production in the context of
community mental health. Consequently, a broad search strategy was
1. Population: Adults aged 18 years or older. developed to ensure that all relevant papers were captured. The
2. Intervention: Co‐produced community‐based mental health interven- search strategy utilized relevant terms for co‐production (e.g., ‘co‐
tions that aim to reduce suicidal risk, thoughts and/or behaviour and/ product*’, ‘co‐design*’, ‘co‐create’), suicide (e.g., ‘sucid*’) and commu-
or those that include subanalyses for participants described as nity mental health (e.g., ‘community mental health’) (see Appendix A,
experiencing suicidal crisis or at risk of suicide were included. e.g., search terms).
Treatment studies focusing upon clinical populations were excluded;
however, co‐produced community‐based studies examining the
effects of prevention interventions to reduce suicide risk (e.g., self‐ 2.4 | Study selection
harm, depression) were included if these data were reported as
separate subanalyses. In addition, studies that broadly focussed upon The primary author removed duplicate studies from the final search
mental health but clearly reported co‐produced outcomes and suicide and independently screened the titles and abstracts of the remaining
prevention outcomes were included. studies against the eligibility criteria. The co‐authors also indepen-
3. Comparator: It was unnecessary for included studies to have control dently screened titles and abstracts according to the inclusion and
group comparators. However, it was expected that some studies such exclusion criteria. Full‐text studies meeting the eligibility criteria were
as randomized‐controlled trials that fulfilled the inclusion criteria retrieved and reviewed for inclusion by the primary author. Two co‐
would compare intervention outcomes with a control group (e.g., authors reviewed all full‐text papers for comparison. Disagreements
usual care). Therefore, comparators could be no intervention or were resolved through discussion within the team at the title and
control group, or comparison with a different intervention group. abstract stage and by one co‐author at the full‐text screening stage.
4. Outcomes: As the goal of suicide prevention interventions is to The PRISMA flowchart documents the screening process (see
prevent suicide, changes in suicide risk and/or suicide‐related Figure 1). Fourteen papers were identified as eligible for inclusion.
behaviours (e.g., suicide ideation) comprised the primary outcome.
Both qualitative and quantitative studies (including cross‐sectional and
longitudinal studies) that assessed changes in suicidal risk and 2.5 | Data extraction and quality assessment
behaviour were assessed against the eligibility criteria. Quantitative
studies using both standardized and nonstandardized measures were Data were extracted by the primary author and transferred onto a
eligible for inclusion. Intervention‐based studies measuring outcomes data extraction sheet that was created and piloted before use. The
over a period of follow‐up were included only if suicide risk was following details were extracted: (1) study characteristics including
reported (e.g., self‐reported) at baseline and at each follow‐up point study design and co‐production definition if included (Table 1) and (2)
and were re‐revaluated at follow‐up at least 1 week beyond baseline. intervention characteristics including intervention type and study
Number of follow‐ups and type of suicide risk behaviour assessed outcomes (Table 2).
were not determinants for inclusion. A narrative evaluation of service
features of interest (e.g., co‐production definition and operationaliza-
tion) was reported. Secondary outcomes were changes in psychologi- 3 | RESULTS
cal well‐being and quality of life.
The PRISMA diagram (Figure 1) illustrates the screening process. Five
Only studies published in English were included and no geographical hundred and ninety papers were identified by searching databases
or publication date restrictions were imposed. This was to capture the (n = 442) and other methods (148). After the removal of duplications
breath of co‐production‐based studies within the literature. and nonrelevant papers (e.g., book titles, conference submissions),
449 titles and abstracts were screened. Of these, 33 papers were
retrieved for full‐text screening. Fourteen studies fulfilled the
2.2 | Search strategy inclusion criteria.
Four electronic databases (PsycINFO, CINAHL, MEDLINE, Web of

Science) were searched. Studies published in English to the 21 March 3.1 | Description of studies
2022 were eligible for inclusion. Filters were not applied during the
search for type of study. Systematic reviews were excluded, but back Table 1 presents a description of the characteristics of the included
searches of reference lists were checked for additional relevant studies. Studies either had a qualitative (n = 6), mixed methods (n = 6)
studies that fulfilled the inclusion criteria. or quantitative design (n = 2). Notably, some studies (n = 5) focused
4 | HANLON ET AL.
FIGURE 1 Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) flow diagram for search outcomes and screening
upon the delivery of suicide prevention interventions online, 3.3 | Synthesis of findings
including via apps (e.g., mobile phone apps) (n = 3), YouTube (n = 1)
or to inform safe online web‐based communications (n = 1). Most of Findings were synthesized to produce a narrative summary describ-
the remaining studies were community‐based and delivered the ing the role of co‐production in community‐based suicide prevention
intervention face‐to‐face (n = 9). Most studies focussed upon suicide interventions.
prevention among younger to older adults aged 16 years or older
(n = 10). One study targeted older adults aged 60 years or older
(n = 1), another focussed upon intervention delivery for adolescents 3.3.1 | Definition and operationalization
and young men (n = 1) and two studies did not stipulate the age of the of co‐production
target population (n = 2).
Half of the studies directly refer to co‐production as a methodological
approach in the design of the suicide prevention interven-
3.2 | Methodological quality tion.38,39,41–43,45,46 None of the studies provide an explicit definition of
co‐production. Rather, most individual studies were found to integrate
The Mixed Methods Appraisal Tool (MMAT)36 and an additional key elements of co‐production within the design and/or delivery of an
question taken from the Quality Assessment with Diverse Studies intervention by involving stakeholders, representing the diverse modes in
(QuADS) quality assessment tool37 to evaluate stakeholder inclusion which co‐production can be applied. All studies featured stakeholders
through co‐production, were used to assess methodological quality. working collaboratively towards some shared goal as a function of co‐
All studies were independently assessed by the first author (C. A. H.) production. Most studies mention stakeholder involvement in the
and the last author (P. S.) independently assessed the quality of 10% development and design of suicide prevention interventions (n = 13). In
of the included studies. MMAT revealed a range in methodological five studies40,44–47 stakeholders, including health professionals and those
quality assessment (see Table 1). However, most studies assessed with lived experience, delivered the suicide prevention interventions.
were of high quality, with nine studies scoring 80%–100%. Studies Also, in five studies, those trained to deliver the suicide prevention
scored low to moderate in quality in terms of co‐production inclusion, intervention worked collaboratively with the recipient, adapting the
appraised using the QUADS as described. No studies were excluded intervention (e.g., safety plans and talk therapy) to suit their individual
from this review based on quality assessment. needs.38,39,41–43 A diverse range of stakeholders participated in the
TABLE 1 Study characteristics
HANLON
Design and methods (inc. measures Quality

used to assess suicide risk/ Focus population of assessment
ET AL.
References Study aims/purpose behaviour) intervention Age range Community setting rating
Bruce and To describe the aims and Descriptive paper, including a Community‐dwelling elderly Focus population age 18 primary care sites MMAT = 20%
Pearson,44 methodology to be used to test fictional case study, which depressed primary care range: 780 aged 60–74 located in 3 QuADS Q = 1
Country: US and evaluate the PROSPECT describes a longitudinal study patients from 18 sites years and 600 aged 75 geographical areas
(Prevention of Suicide in Primary design planned to be used to test within 3 geographical areas years and older.
Care Elderly: Collaborative Trial) and evaluate the PROSPECT in the US were the focus
intervention, a model of intervention. population, with
depression recognition and Proposed use of the Centers for the collaborative working
treatment aimed at preventing Epidemiologic Studies Depression between physicians and
and reducing suicide among (CESD) scale to screen potential health care specialists.
older adults. participants for depression during
recruitment. Eligible participants
would undergo further in‐person
assessment for depression and
other clinical, neuropsychological
and social variables. Telephone
follow‐ups at 4 and 8 months and
bi‐annual administration of the
full research assessment battery
are proposed. It is unclear what
measures would determine
depression‐ and suicide‐related
risk/behaviours beyond screening
participants for inclusion.
Buus et al.,49 To examine stakeholders' An instrumental case study involving People in or at risk of suicide Reported mean age range Online—A Safety MMAT = 80%
Country: suggestions and contributions to a qualitative study using focus crisis. Study participants, of participants: 16–46 planning mobile QuADS Q = 2
Australia and the design, function and content groups and participatory including MYPLAN app years. phone app
Denmark in the development of an workshops. users, relatives and
existing app called MYPLAN clinicians, worked
aimed towards individuals in or collaboratively with the
at risk of suicidal crisis. researchers and software
developers revised the app.
Cheng et al.,50 Aimed to investigate the impacts of Mixed methods. Qualitative analysis Social media users (e.g., Viewers of the YouTube Online—Youtube video MMAT = 80%
Country: promoting suicide prevention of the co‐creation process in the YouTube). short film ages ranged QuADS Q = 1
Hong Kong using social media and to development of a YouTube suicide from 13 to 44 years.
evaluate the co‐creation process prevention short film. Video Respondents filled in an
involving a popular YouTuber. statistics (e.g., views) generated online survey—ages are
online, an online survey and reported to have ranged
online public comments evaluated from 12 to below 65
video impact and effectiveness. years.
|
(Continues)
5
6
TABLE 1 (Continued)
|

Suicide risk/behaviours assessed

within the online survey using two
questions about suicide thoughts
in the past 12 months and help‐
seeking.
Chopra et al.,38 Aimed to evaluate the effectiveness Case series study involving Adult men experiencing Adults aged 18 years and Community‐based, face MMAT = 80%
Country: UK of James' Place Model and to quantitative assessment of suicidal crisis. older. to face QuADS = 1
conduct a social value James' Place Model effectiveness.
assessment of the service to Suicide risk assessment conducted
provide an understanding of the collaboratively between a
potential social, economic and therapist and service user with a
environmental impact of James’ safety plan, a CORE‐OM self‐
Place. report questionnaire, referrer
evaluation of precipitating factors
(e.g., relationship breakdown) and
therapist assessment of various
psychological, motivational and
volitional factors (e.g.,
entrapment, perceived
burdensomeness).
Ferguson This study aimed to explore the Qualitative study involving Refugees and asylum seeker Age not given Unclear MMAT = 100%
et al.,39 perspectives and experiences of semistructured interviews with clients. QuADS = 1
Country: workers providing case workers from nongovernment
Australia management, support or organizations providing case
counselling to refugee and management, support or
asylum seeker clients on co‐ counselling to refugees and
developed personalized safety asylum seekers.
plans.
Hetrick et al.,48 This study aimed to Co‐design with Participatory design and studio Young people experiencing Young people aged 18–24 Online community MMAT = 100%
Country: young people a mobile phone design method were used in the depression years. QuADS = 3
Australia app‐based self‐monitoring mood development of the app, which
tool that facilitates followed human‐centred
communication of this with a principles. This involved
clinician. workshops and focus groups with
young people and clinicians.
Richardson The Young Men and Suicide Project Mixed methods involving a literature Young men Northern Ireland initiative School MMAT = 60%
et al.,40 (YMSP) aimed to develop a review to identify best practice, targeted adolescents Online QuADS = 2
range of mental health initiatives online surveys with stakeholders (age not specified).
HANLON
ET AL.
TABLE 1 (Continued)
HANLON

ET AL.
Country: Ireland to promote positive mental including community‐based Southern Ireland initiative
(both health among young men in services, education services and targeted young men
Northern & Ireland and to assess the efficacy prisons and focus groups service (age not specified).
Southern of these. providers and men to understand
Ireland) what works with young men in
mental health service provision.
Findings informed the
development and piloting of two
initiatives called ‘Mind Yourself’
and ‘Work out’.
Pre‐ and postmeasures of self‐
esteem, depression and resilience
were assessed in the Mind
Yourself programme.
Validated psychometric tests (e.g., six
items from the General Health
Questionnaire‐12 [GHQ‐12])
taken pre‐, during and
postintervention in the ‘work out’
programme assess changes in
mental fitness.
Saini et al.,41 This study aimed to evaluate the Mixed methods. Qualitative methods Adult men experiencing 18 years and older Community‐based, MMAT = 100%
Country: UK effectiveness of the James' Place included semistructured suicidal crisis. face‐to‐face QuADS = 1
Mode in reducing suicidality in interviews with men who had delivery of a suicide
men using the service and to used the service and written prevention model
conduct a social value responses to interview questions
assessment of the service to from a GP. Quantitative analyses
provide an understanding of the of pre‐ and postoutcome data.
potential social, economic and Quantitative and qualitative
environmental impact of findings were triangulated to
James' Place. understand the wider social value
of James' Place.
Suicide risk assessment conducted
collaboratively between a
therapist and service user with a
safety plan, CORE‐OM self‐report
questionnaire, referrer evaluation
of precipitating factors (e.g.,
relationship breakdown) and
|
(Continues)
7
8
TABLE 1 (Continued)
|


burdensomeness).
Saini et al.,42 This study aimed to evaluate the Mixed methods. Semistructured Adult men experiencing 18 years and older Community‐based, MMAT = 100%
Country: UK effectiveness of the James' Place qualitive interviews with suicidal crisis. face‐to‐face service QuADS = 1
Model in reducing suicidality in therapists. Quantitative analyses temporarily moved
men over a 2‐year period and to of pre‐ and post‐CORE‐OM to online delivery
compare the findings pre‐ and outcome data to assess the during the COVID‐
post‐COVID‐19 pandemic. effectiveness of the James' Place 19 pandemic
Model.
burdensomeness).
Saini et al.,43 Aimed to evaluate an innovative Case series study involving Adult men experiencing 18 years and older (age Community‐based, MMAT = 40%
Country: UK suicidal crisis intervention for quantitative assessment CORE‐ suicidal crisis. range 18–66 years) face‐to‐face QuADS = 3
younger men (18–30 years) OM scores and clinical records of delivery of a suicide
versus older men (31 years and psychological, motivational and prevention model.
older). volitional factors associated with
participants' suicidal crisis and
CORE‐OM scores.
HANLON
ET AL.
TABLE 1 (Continued)
HANLON

ET AL.

burdensomeness).
Thorn et al.,51 This study aimed to improve Mixed methods. Participatory co‐ Young people accessing 17–25 years Online community MMAT = 80%
Country: dissemination of and design approach involving 11 the web QuADS = 3
Australia engagement with the #Chatsafe workshops with young people.
guidelines by including young Workshop activities included a
people in the design and warm‐up, co‐design activities
development of a social media evaluation and cooldown. At the
campaign to promote safe web‐ end of each workshop,
based communications about participants were invited to
suicide. Objectives of the study complete a quantitative
were to document key elements evaluation survey including
of the co‐design process, questions on demographics,
evaluate young people's perceived benefits from
experiences of the co‐ participation and workshop
design process and capture acceptability and safety. Safety
young people's protocols (e.g., wellness plan) and
recommendations for the monitoring (e.g., workshop
#Chatsafe suicide prevention evaluation survey/debrief) were
campaign. included.
Wilcock et al.,45 Evaluation of the Offload Mixed methods involving pre‐ and Community, sport‐based Men aged 16 years or older Community‐based MMAT = 60%
Country: UK programme, a men's rugby‐ post‐intervention questionnaires intervention for men QuADS = 3
league community‐based mental (n = 699) exploring aspects related experiencing mental health
health programme. to health and well‐being (e.g., illness (anxiety and
resilience, social support). Also, depression) to prevent
focus groups and case studies development of complex
with men who engaged with the mental illness and suicide.
Offload programme.
Provision was available to assess men
using the Patient Health
Questionnaire‐9 (PHQ9) and/or
the General Anxiety Disorder
scale (GAD7) if facilitators
delivering the intervention were
concerned about a participant's
well‐being. Facilitators were also
able to seek advice from a mental
health clinician. These measures
|
(Continues)
9
10
TABLE 1 (Continued)
|

were not routinely given for the

assessment of suicidal risk/
behaviours. Men did, however,
self‐report mental health
conditions/diagnoses.
Wilcock et al.,46 This study aimed to explore Qualitative study involving one‐to‐ Community, sports‐based Intervention targets men Community‐based MMAT = 100%
Country: UK stakeholder perspectives of the one semistructured interviews intervention for men aged 16 years or older. QuADS = 2
key design characteristics and with 18 programme designers and experiencing mental health
the roles played by delivery staff delivery staff. illness (anxiety and
in the conception and depression) to prevent
development of a community‐ development of complex
based men's rugby mental health mental illness and suicide.
programme called Offload.
Zealberg et al.,47 To describe the development of the Descriptive paper outlining Community population Age of the focus population Community‐based MMAT = 40%
Country: US collaboration between development of a mobile crisis experiencing psychiatric not specified. QuADS = 1
emergency psychiatric services programme involving crisis.
and the police. collaboration between emergency
psychiatric services and the
police, which includes case
studies to illustrate collaboration.
It is unclear how suicidal risk/
behaviours were determined.
However, it appears that this
involved a subjective or clinical
assessment (e.g., a clinical history)
of the situation made by police
and/or psychiatric team members
responding to incidents.
Note: MMAT refers to the Mixed Methods Appraisal Tool.36 QuADS Q refers to the question derived from the Quality Assessment with Diverse Studies quality assessment tools.37
HANLON
ET AL.
HANLON ET AL. | 11
TABLE 2 Intervention characteristics
Co‐production and/or suicide‐related

References Intervention details Co‐production methodological approach outcomes
Bruce Delivery of a comprehensive treatment Collaboration between a health specialist No co‐production outcomes(s)
and Pearson44 algorithm for depression adapted (e.g., nurse, social worker or clinical provided.
from the Agency for Health Care psychologist) and physician to facilitate Outcomes proposed to assess the
Police and Research (AHCPR) timely and targeted identification and effectiveness and impact of the
guidelines. Antidepressant therapy or treatment of depression among older intervention relate to depressive
Interpersonal Therapy (IPT), if adults. It was proposed that the health symptomatology (e.g., suicide
antidepressants were unwanted by specialist would liaise with the patient, ideation, hopelessness, depression
the patient, was to be recommended. help the physician to recognize and suicidal risk behaviours
A health specialist (e.g., nurse, social depression and make treatment including substance abuse and
worker or clinical psychologist) was to recommendations within the remit of disturbed sleep). Authors estimated
‘prompt’ physicians to facilitate timely the PROSPECT intervention guidelines that 18% of participants would
and recommended treatment based upon patient information/ experience depression at baseline.
decisions by advocating for patients monitoring and encourage treatment No evaluation of suicide‐related
(e.g., obtaining and providing adherence among patients. outcomes provided.
feedback of information on patient
symptoms and treatment experiences
to the physician). Education was also
to be provided to patients, families
and physicians on depression and
suicide ideation. However, it is
unclear who delivered this aspect of
the intervention.
Buus et al.49 App‐based intervention called MYPLAN Focus groups and participatory workshops Thematic analysis led to the
combining three preventative were used to further develop the development of 3 phases of user
strategies around safety planning, MYPLAN intervention. This involved involvement in the development of
help‐seeking from peers and engagement between participants, the MYPLAN app relating to
professionals and restriction of access software developers and researchers in ‘suggestions of core functions’,
to lethal means. An additional feature the design, evaluation and revision of ‘refining functions’ and ‘negotiating
promotes help‐seeking behaviour by MYPLAN app prototypes in response finish’. Increased participant
including a map and directions to an to participant feedback. Emphasis was engagement with researchers and
emergency room nearest to the users' placed upon personal experiences of software developers during the later
location. using MYPLAN and evaluation of its stages of user‐involving processes
wireframe, functionality and whether as the app became increasingly
the app was culturally suited to an revised.
Australian user audience. Software The revised MYPLAN app included the
developers revised and developed suicidal ideation attributes scale
prototypes in response to user (SIDAS) to measure suicide ideation,
feedback. a mood ratings tracker and a
customizable list of personal
warning signs of crisis. No
evaluation of the impact of the
intervention upon suicidal risk/
behaviours reported.
Cheng et al.50 Short film designed to reduce suicidality Co‐creation of a YouTube short film Thematic analyses of the co‐creation
and promote help‐seeking involving a popular YouTuber and process identified three facilitating
behaviours. The storyline of the film researchers. To inform this process, the factors of ‘shared concern about
focused upon a suicidal university YouTuber engaged with literature, youth suicide prevention’, ‘enriched
student and a taxi driver who online material and staff and clients knowledge of lived experience with
encourages the former to seek help. from a local suicide survivor service. suicide’ and ‘preserve the
Also featured is an obscured scene of uniqueness of the YouTuber’, and
a suicide method (hanging). one barrier: ‘the balance between
realism and appropriateness of
content’.
Overall, positive perceived changes in
audience suicide prevention
knowledge, attitudes and
behaviours reported. Mixed views
received from qualitative feedback
(Continues)
12 | HANLON ET AL.
TABLE 2 (Continued)

and public comments. Some

respondents who had suicidal
thoughts and provided qualitative
feedback (n = 22) reported that the
storyline resonated with their
situation (e.g., academic and life
stress; n = 6), one felt that the film
helped to alleviate stress and
another felt that it motivated them
to live. Three respondents criticized
the film.
Public comments (n = 164) generally
supported the film (e.g., 10.8%
showed support to people in
distress). Eight commentators
reported past suicidal thoughts; four
had attempted suicide. Two
commentators with suicide intent
reported abandoning their suicide
plans after watching the film. One
commentator displayed current
suicidal thoughts and another
endorsed suicide as an option.
Chopra et al.38 A community‐based suicide prevention Co‐production of the suicide prevention Feedback evaluations completed by
intervention underpinned by three intervention and safety planning with 18% of men (39/212) indicated that
prominent suicidal theories men engaged in the service and the James' Place service was
(interpersonal theory of the suicide, therapists delivering the James' Place perceived as a safe and welcoming
collaborative assessment and Model. Co‐production with therapeutic setting and improved
management of suicidality and the stakeholders (including academics, overall mental well‐being and
integrated motivational–volitional clinicians, commissioners, therapists coping. No formal evaluation of co‐
theory of suicide). Emphasis is on the and experts‐by‐experience) also production reported.
therapist and service user co‐ informed service inception, design and Significant mean reduction in CORE‐
producing the therapeutic delivery. OM scores for men who completed
intervention together. Brief assessment and discharge
therapeutic approaches and questionnaires. No relationship
interventions (e.g., behavioural found between the precipitating
activation, sleep hygiene) focussed factors and levels of general
upon reducing suicidal distress and distress, or between those with or
developing resilience and coping are without each precipitating factors.
delivered.
Ferguson et al.39 To explore the perspectives and Co‐production discussed in the context of Four themes developed: ‘Safety
experiences from workers who co‐creating safety plans. The theme planning as a co‐created,
provide case management, support or from worker interviews, ‘safety personalised activity for the client’;
counselling to refugee and asylum planning as a co‐created, personalised ‘therapeutic benefits of developing a
seeker clients on co‐created activity’, highlights the workers' safety plan’; ‘barriers to engaging in
personalized safety plans. perspectives that safety planning safety planning’ and ‘strategies to
should be a collaborative process and enhance safety planning
personalized to the individual. engagement’. Overall, these
highlight the perceived facilitators,
barriers and strategies to enhance
safety planning as a suicide
prevention intervention for refugees
and asylum seekers. Benefits of co‐
production reported included
equitable working relationship
between the client and the worker,
recognition of the client's expertise
and flexibility and creativity to tailor
HANLON ET AL. | 13
TABLE 2 (Continued)

and co‐creation safety planning

using alternative modes (e.g.,
photographs, drawings).
Perceived therapeutic benefits of co‐
created safety planning included
increased awareness of distress
triggers among clients and coping
strategies, use of personalized
strategies to interrupt suicidal
thoughts and normalization of their
suicidal experience.
No formal evaluation of suicide‐related
outcomes provided.
Hetrick et al.48 Development of a mobile phone app Co‐design workshops with young people Various app features supported co‐
designed to enable monitoring of and two focus groups with clinicians production between the app user
mood with feedback for users and designed to elicit information sharing and clinician (e.g., the onboarding
clinicians. Users able to customize the and generation of concepts for the app. process, tailoring of trigger points
app to suit their preferences. Features Young people sketched design features within the well‐being checker).
included mood monitoring (named of the app and gained feedback from The well‐being tracker mood rating
‘well‐being checker’) with space to the group on their individual design. function incorporated trigger points
record factors influencing users' The group created a design using the for high distress to assess suicide
mood; brief personalized best ideas from individual designs in a risk/behaviours. No formal
interventions to support young process called feature prioritization. evaluation of the effectiveness of
people in the time between face‐to‐ This informed subsequent co‐ the app in reducing suicidal risk/
face appointments linked to the well‐ design rounds until consolidation of the behaviours was reported, but it was
being tracker such as distraction best ideas resulted in the final design. proposed that it could enhance
techniques to reduce stress (e.g., Clinicians proposed their needs and help‐seeking.
meditation, games and breathing concerns of monitoring young people
techniques) and a photo album to using an app before the co‐
promote positive emotion (e.g., design workshops took place. In a
photos, supportive messages from second focus group with clinicians, a
friends and loved ones, music young person involved in the co‐
playlists); lastly, a one‐touch safety design workshops presented the app
feature enabling users to contact wireframes and clinician feedback
emergency services and their gained on the app design and its use in
supporters. practice.
Richardson Northern Ireland: ‘First Instinct’ a whole Various components of intervention Facilitators of Mind Yourself perceived
et al.40 community approach, aimed to design, development and delivery the programme as effective, but
encourage help‐seeking among the involved co‐production. An advisory some barriers were identified (e.g.,
young men. This involved group of key men's health and suicide literacy issues hindering
development of the ‘Mind Yourself’ prevention representatives supported questionnaire completion). Positive
brief mental health intervention; and oversaw intervention feedback from the young men
young men's advisory/reference development. Local stakeholder (e.g., advisory/reference group reported
group; training programmes for from community‐based services, suggested that participants
practitioners focused upon education services, prisons and young reflected positively upon their
developing work with men and men) views on the extent and nature of involvement (e.g., welcomed the
creation of a ‘working with men’ mental health/suicide prevention opportunity to focus on issues
resource library offering off‐the‐shelf initiatives for young men in Ireland and affecting men in an equitable way
resources for practitioners. the perceived facilitators and barriers with other stakeholders). Mind
Southern Ireland: ‘Work Out’, a mental of working with young men elicited Yourself evaluation showed no
fitness app, was developed that aimed through surveys and focus groups significant change in pre‐ and
to improve help‐seeking, social informed intervention development. postmeasures of self‐esteem,
connectedness and mental health Northern Ireland: Local community depression and resilience.
literacy. Comprised of a series of brief members delivered the Mind Yourself Feedback‐suggested Work Out was
online interventions (called ‘missions’) programme. A young men's advisory perceived as acceptable and
underpinned by cognitive behavioural forum/reference group was set up by accessible. No suicide‐related
therapy principles that aimed to staff from a local organization and outcomes reported.
address four areas: being practical,
(Continues)
14 | HANLON ET AL.
TABLE 2 (Continued)

building confidence, taking control involved local youth leaders as ‘co‐

and being a team player. workers’ and facilitators in its delivery.
Southern Ireland intervention
development involved collaborative
working between developers of the
Irish version of ‘work out’ and
developers of the Australian version
through data sharing. Focus groups
involving young men provided
feedback on ‘Work out’ during
intervention development and testing.
Saini et al.41 A community‐based suicide prevention Co‐production of the suicide prevention Elements of co‐production were
intervention underpinned by three intervention and safety planning with evident in the design and delivery of
prominent suicidal theories men engaged in the service and the James' Place Model. For
(interpersonal theory of the suicide, therapists delivering the James' Place example, men spoke of the utility of
collaborative assessment and Model. Co‐production with the ‘lay your cards on the table’
management of suicidality and stakeholders (including academics, component for exploring factors
integrated motivational‐volitional clinicians, commissioners, therapists underpinning their suicidal crisis and
theory of suicide). and experts‐by‐experience) also for exploring coping strategies, and
Emphasis is on the therapist and service informed service inception, design and described improved mood,
user co‐producing the therapeutic delivery. motivation and family relationships.
intervention together. Brief No formal evaluation of co‐
therapeutic approaches and production provided.
interventions (e.g., behavioural Impact of the intervention on suicidal
activation, sleep hygiene) focussed crisis evaluated using CORE‐OM
upon reducing suicidal distress and scores. The initial overall mean
developing resilience and coping are CORE‐OM score on entry to the
delivered. service was reported as 85.5
(n = 137) and the mean overall
discharge score was reported as
38.9 (n = 60). The mean reduction in
CORE‐OM scores was reported as
46.6. Psychological factors related
to men's suicidality (e.g., impulsivity,
thwarted belonginess, hopelessness)
reported. No relationship between
precipitating factors and general
distress levels found at initial
assessment, or between those with
and without each precipitating
factors found.
Saini et al.42 A community‐based suicide prevention Co‐production of the suicide prevention Co‐production evidenced within
intervention underpinned by three intervention and safety planning with therapist interviews in the
prominent suicidal theories men engaged in the service and management of men engaged in the
(interpersonal theory of the suicide, therapists delivering the James' Place service during remote delivery of
collaborative assessment and Model. Co‐production with the James' Place Model. Formal
management of suicidality and stakeholders (including academics, evaluation of co‐production was not
integrated motivational–volitional clinicians, commissioners, therapists performed.
theory of suicide). and experts‐by‐experience) also Impact of the intervention on suicidal
Emphasis is on the therapist and service informed service inception, design and crisis evaluated using CORE‐OM
user co‐producing the therapeutic delivery. scores. Evaluation of 2‐year
intervention together. Brief intervention effectiveness showed
therapeutic approaches and an initial overall mean CORE‐OM
interventions (e.g., behavioural score on entry to the service of
activation, sleep hygiene) focussed 86.56 (n = 322) and a mean overall
upon reducing suicidal distress and discharge score of 35.45 (n = 145).
developing resilience and coping are The mean reduction in CORE‐OM
delivered. scores was reported as 50.9.
HANLON ET AL. | 15
TABLE 2 (Continued)

Evaluation of CORE‐OM scores

suggested that the James' Place
model was as effective, if not more,
during COVID‐19.
Saini et al.43 A community‐based intervention Co‐production of the suicide prevention A clinically significant reduction in the
underpinned by three prominent intervention and safety planning with mean CORE‐OM scores between
suicidal theories (interpersonal theory men engaged in the service and assessment and discharge for both
of the suicide, collaborative therapists delivering the James' Place younger and older men engaged
assessment and management of Model. Co‐production with with the James' Place Model
suicidality and integrated stakeholders (including academics, intervention reported. No significant
motivational–volitional theory of clinicians, commissioners, therapists difference in distress scores
suicide). Emphasis is on the therapist and experts‐by‐experience) also between younger versus older men
and service user co‐producing the informed service inception, design and at assessment and discharge.
therapeutic intervention together. delivery. However, younger men showed
Brief therapeutic approaches and lower levels of distress compared to
interventions (e.g., behavioural older men at initial assessment and
activation, sleep hygiene) focussed lower levels of wellness than older
upon reducing suicidal distress and men at discharge. No formal
developing resilience and coping are evaluation of co‐production.
delivered. Assessment of psychological,
motivational and volitional factors
reported. Younger men were less
affected by entrapment, defeat not
engaging in new goals and had
positive attitudes towards suicide
than older men at assessment. Older
men at discharge were significantly
more likely to have an absence of
positive future thinking, less social
support and entrapment than
younger men.
Thorn et al.51 A social media campaign aiming to An iterative process of co‐design whereby Overall, co‐design workshops were
promote safe web‐based learning from workshops informed the perceived by participants as
communication about suicide. next workshop. Workshop facilitators acceptable, beneficial and safe,
(e.g., researchers and designers) guided although some participants reported
design activities. Co‐design activities feeling suicidal (n = 8) or unsure
facilitated peer‐to‐peer mapping of whether they felt suicidal (n = 6)
young people's social media usage and after workshops. Findings support
communication of suicide on the web, the feasibility of safe involvement of
idea generation (e.g., campaign themes young people in the development of
and content) and testing of and co‐designed recommendations (e.g.,
feedback on the design protocol for the content and format) for a web‐
campaign. Three key elements based suicide prevention campaign
comprised the co‐design process: 1. to enhance its acceptability among
‘Define’ involved mapping young young people.
people's social media usage, their Positive outcomes of feelings of
communication about suicide and improved ability to communicate
determined how young people wanted online about suicide and to identify
#Chatsafe guidelines to be integrated others who may be at risk of suicide
into the campaign; 2. ‘Design’ involved were reported.
integrating young people's
perspectives and addressing their
wants and needs in the campaign
development including campaign
themes and delivery methods; 3. ‘User‐
testing’ involved prototype testing and
gaining feedback. A collaborative
approach ensured participant safety
(Continues)
16 | HANLON ET AL.
TABLE 2 (Continued)

(e.g., a researcher accompanied

distressed participants to a private
space to enact the young person's
wellness plan).
Wilcock et al.45 Ten‐week, education‐based intervention Coproduction is evident in the design and The co‐produced programme content
that uses the rugby league brand to delivery of Offload. The design phase was perceived as more relatable.
address low‐level mental health involved collaborative working Accessibility, use of nonclinical
problems (e.g., low self‐esteem, partnerships between Rugby League language and informal setting (i.e.,
depression and anxiety). Rugby‐ Cares, State of Mind, three Rugby rugby league stadiums) were
related language is used to normalize League Club's charitable foundations perceived to encourage help‐
mental health, promote intervention (Salford Red Devils Foundation, seeking and to remove stigma.
accessibility, acceptability, Warrington Wolves Foundation and Additional reported benefits include
engagement and adherence. Vikings Sports Foundation) and over increased confidence and self‐
Comprised of 10 sessions (called 200 men from the targeted population esteem, improved coping, social
‘fixtures’) aimed at raising awareness who participated in interviews, focus connectedness, increased social
of mental health problems (e.g., low groups and questionnaires exploring support, willingness to talk about
self‐esteem, anxiety, depression), their views of mental health mental health and reduced suicide
tackling stigma and encouraging the intervention provision. Findings from ideation and/or attempts.
development of coping strategies. men's participation informed the Pre‐ and postintervention questionnaire
Sessions were comprised of two, intervention name, where (i.e., from findings showed positive
40‐min halves. rugby stadiums) and when the improvement in nine outcomes
intervention is delivered, the language reported relating to areas including
used (i.e., rugby‐centric) and the coping, resilience, engagement in
content of the intervention (e.g., type sport and identification of support
of self‐care tools to use). Foundation around the men. For example,
managers/lead, former players and approximately three‐quarters of
coaches, officials, mental health and participants reported improved
mindfulness specialists were involved awareness of how to look after their
in the delivery of Offload. health and well‐being, coping and
better able to manage setbacks and
challenges.
Wilcock et al.46 Ten‐week, education‐based intervention Coproduction is evident in the design and Thematic analysis generated three
that uses the rugby league brand to delivery of Offload. The design phase themes reflecting the importance of
address low‐level mental health involved collaborative working co‐production in the co‐design of
problems (e.g., low self‐esteem, partnerships between Rugby League the intervention: ‘tacit forms of
depression and anxiety). Rugby‐ Cares, State of Mind, three Rugby knowledge are essential to initial
related language is used to normalize League Club's charitable foundations programme designed’; ‘stigma‐free
mental health, promote intervention (Salford Red Devils Foundation, and non‐clinical environments
accessibility, acceptability, Warrington Wolves Foundation and appeal to and engage men’ and
engagement and adherence. Vikings Sports Foundation) and over ‘lived experience and the relatability
Comprised of 10 sessions (called 200 men from the targeted population of personal adversity’. Co‐
‘fixtures’) aimed at raising awareness who participated in interviews, focus production was perceived to
of mental health problems (e.g., low groups and questionnaires exploring improve intervention reach and
self‐esteem, anxiety, depression), their views of mental health engagement by using
tackling stigma and encouraging the intervention provision. Findings from nonstigmatizing language and
development of coping strategies. men's participation informed the delivering the intervention in a
Sessions were comprised of two, 40‐ intervention name, where (i.e., from nonjudgmental, nonclinical
min halves. rugby stadiums) and when the environment. Delivery of solution‐
intervention is delivered, the language focused activities provided by men
used (i.e., rugby‐centric) and the with lived experience was perceived
content of the intervention (e.g., type to promote relatability and
of self‐care tools to use). Foundation trustworthiness.
managers/lead, former players and Suicide‐related outcomes were not
coaches, officials, mental health and formally evaluated. Delivery of the
mindfulness specialists were involved intervention by former professional
in the delivery of Offload. sportspeople who recalled their
lived experience of mental illness/
adversity was perceived to possibly
HANLON ET AL. | 17
TABLE 2 (Continued)

promote modelling of alternative

masculine behaviours that could
potentially enhance mental health
and help‐seeking.
Zealberg et al.47 An emergency psychiatry‐mobile crisis Collaboration between the police and Outcomes reported relate to three case
programme linking key professionals, clinicians allowed clinicians to liaise studies and involve de‐escalation of
specifically mental health with the individual experiencing crisis police incidents with individuals
professionals (e.g., Master's‐level to encourage a peaceful resolution to experiencing crisis.
clinicians in nursing, counselling, specific situations. This was facilitated
psychology, social work) with the through regular meetings with law
police to provide mobile, crisis enforcement officials, reclarification of
intervention. Clinicians supported mutual responsibilities and
police officers in a consultative role expectations and reviewing of critical
during police incidences involving situations. This partnership was further
people experiencing serious mental affirmed through debriefing of police
health illness. Clinicians would obtain officers following incidents, providing
a history from the individual, mental health referrals for police
neighbours, family and friends, drug officers and being informal consultants.
and alcohol use and establish trust
and a therapeutic alliance with the
individual. Details on three case
studies are provided and intervention
techniques, for example developing a
rapid therapeutic alliance with a
woman threatening to jump from a
ledge and holding her there while
police assembled a safety net below.
studies. Stakeholders included health professionals, clinicians, mental experiencing suicidal crisis.38,41–43 Co‐production was integrated in the
health specialists, police officers,38–49 community representatives includ- creation of personalized safety plans for asylum seekers and refugees.39
ing sporting representatives (e.g., ex‐rugby players) and community Discussions acted as a forum for rapport building, enabling
leaders,38,40–43,45,46 YouTubers,50 those who are representative of theor improved collaboration between diverse professional disciplines and
with lived experience/or with lived experience.38,40–43,45,46,48–51 people with lived experience. For example, Zealberg et al.47 attribute
Key success factor ‘prior working discussions’ with local police agencies to redressing
problems and building trust within the collaborative working
3.3.2 | Facilitators of co‐production relationship, a key factor in the successful implementation of their
suicide prevention intervention. Studies identified that discussions
Stakeholders mainly engaged through an iterative process to elicit their among stakeholders provided an opportunity for negotiation and
perspectives on functional aspects and/or the content of the design and consensus‐seeking when addressing disagreements that may arise
development of the suicide prevention intervention (n = 13). This was during intervention development or delivery.40,47–50 Cheng et al.50
40,45,46,48,49,51
facilitated either through focus groups/workshops and/or report that researchers expressed concern over the inclusion of a
one‐to‐one discussions with stakeholders including researchers, those suicide scene of hanging in the co‐creation of a suicide prevention
38,39,41–43,45,46,50
with lived experiences and a YouTuber. Seven stud- video with a YouTuber for example. The YouTuber felt that the
ies38,39,41–44,47 integrated co‐production that was discursive in nature inclusion of this scene was imperative to maintaining the authenticity
between key partners during the delivery of the suicide prevention of the video's storyline. However, the YouTuber adapted the scene
intervention. In Bruce and Pearson's44 study, a health professional was once the researchers explained the potential for contagion effects.
nominated to advocate for the patient and to assist physicians in the
recognition of depression to allow timely intervention. In contrast,
discussions around the intervention and to troubleshoot potential 3.3.3 | Challenges of co‐production
problems that may occur during implementation were held between
local police agencies before and during intervention delivery in Zealberg The evidence highlights some challenges that may hinder the
et al.47 Conversely, co‐production informed service design and delivery of inclusion of co‐production in the design and/or implementation of
four studies focusing upon a suicide prevention intervention for men suicide prevention interventions. During co‐production, both parties
18 | HANLON ET AL.
must be willing to engage when working collaboratively. This issue is the views of service providers and young men considered. This
highlighted in Ferguson et al.'s39 study exploring the views and revealed to the researchers the issues that men experience that may
perspectives of workers supporting asylum seekers and refuges in the place them at risk of suicide such as ‘resistance to connection’ and
co‐creation of safety planning. Workers perceived a lack of ‘client ‘stigma attached to mental illness and mental health’ and ways to
readiness’ to engage in safety planning (e.g., unwillingness to write a better engage and reach young men within community settings. This
safety plan down) as a potential barrier hindering the co‐ acquired new learning‐informed intervention development that
production of personalized safety planning. engaged community partnerships and young men from the targeted
A reluctance of professionals to relinquish power was evident. population. For example, ‘train the trainer’ within the Mind Yourself
Hetrick et al.48 reported clinician resistance towards the inclusion of intervention enabled facilitators to consider different ways of
service users in shared decision‐making and accessing a mobile App engaging the targeted population before formal delivery. Similarly,
49
(mApp). Similarly, Buus et al. reported that software designers in setting up a suicide prevention service for men, diverse
included a suicidality rating scale against the wishes of stakeholders stakeholder views informed service inception, design and delivery
involved in the design and development of an mApp. Conversely, of James' Place reported in Chopra et al.38 and Saini et al.41–43
three studies emphasize the importance of each stakeholder New knowledge acquired through stakeholder involvement led
maintaining the boundary of their individual area of expertise when to intervention development with content adapted to suit the
working in partnership.47–49 Failure to do so could affect the safety targeted population. Buus et al.49 described how participants
47
of professionals and service users during intervention delivery and involved in the co‐design adapted features of their mApp‐based
unduly burden parents/clinicians with notifications alerting them to suicide prevention intervention. This included mood descriptors that
the suicidality risk of their child/patient,49 particularly out of working could be customized by the user and change nonclinical language
hours.48 Some safeguarding concerns were highlighted. These used to describe core functions of the app (e.g., ‘warning signs’ was
centred around whether participation may have induced suicidal changed to ‘well‐being checker’). This is also evident in the delivery of
feelings and50,51 also the implications of clinicians being alerted to the James' Place Model, where co‐production is used to tailor the
client suicidality out of hours and not being able to respond to this.48 suicide prevention intervention to suit the individual needs of
Similarly, Thorn et al.51 highlight some challenges of gaining ethical men.38,41–43 Similarly, Ferguson et al.39 reported that participants in
approval to undertake co‐productive methodologies in suicide their study recognized individuals as being the expert of their own life
prevention research, and the additional burden on resources that when co‐creating and co‐developing safety plans with refugees and
safety protocol development and the monitoring of stakeholder well‐ asylum seeker clients. Also, the rugby‐themed Offload pro-
being may have. gramme45,46 was perceived as more relatable as it was delivered by
those with lived experience of mental health conditions, used
nonclinical language and was implemented within an informal,
3.3.4 | Benefits of co‐production nonclinical environment (i.e., Rugby stadiums). In this sense, co‐
production provides voice and autonomy in decision‐making for
Integrating co‐production within the methodological approaches individuals accessing a suicide prevention intervention.
provided opportunity for knowledge sharing between partners to
create new knowledge that could be applied to shape aspects of the
suicide prevention intervention design and/or delivery. Areas of new 3.4 | Outcomes associated with co‐produced
knowledge included the identification of gaps in existing suicide community‐based suicide prevention interventions
prevention approaches, the adaptation of suicide prevention inter-
ventions to better suit intervention user needs and to improve reach Eleven studies reported participants gaining positive and enriching
among the targeted population. For example, Thorn et al.51 used new experiences from their involvement in co‐production‐
learning generated in stakeholder workshops to inform the schedule based methodologies irrespective of the nature of this involvement
of subsequent workshops during the design and development of a (e.g., co‐design, co‐production of the suicide prevention intervention,
suicide prevention campaign associated with the #Chatsafe project to etc.). These included beneficial/suicide literacy,51 enthusiasm,48
improve reach among the targeted population. therapeutic benefits including normalizing suicidal experiences and
The consultation of stakeholders, whether they have profes- being able to identify unique triggers and coping strategies,39 rapport
sional or lived experience expertise, encourages consideration of and trust building,47 an enriching process,50 sharing of experiences in
suicidality and suicide‐related risk factors through a different lens. focus groups/debrief,49 receiving psychological support within a safe
Including stakeholders with lived experience promotes reaching back and supportive therapeutic environment,41 improved relationships,
to gain a deeper understanding of the issues that matter, informing coping and understanding of health and well‐being needs45 and being
the adaptation of suicide prevention interventions to suit the needs involved in the decision‐making process alongside the therapist
and preferences of their targeted population. This effect is reported during the co‐production of therapy.38,41,42
in 12 studies.38–43,45,46,48–51 Richardson et al.40 undertook an A lack of formal evaluation of outcomes associated with the
extensive consultative process involving an advisory group, with suicide prevention intervention is evident. This is likely in part due to
HANLON ET AL. | 19
the type of studies included, the majority of which focused upon the 4 | D IS CU SS IO N
co‐design of the intervention. Nine studies38,40–45,47,50 propose or
report some evaluation of the intervention impact. However, only half This review has synthesized research evidence to understand how
embedded formal evaluation of outcomes pre‐ and postdelivery of the co‐production is defined and operationalized, and to examine how
intervention.38,40–45 Bruce and Pearson44 proposed baseline measure- co‐production is implemented. In addition, the aim was to evaluate
ment of various measures in their study, including depression and the outcomes assessed and to identify core components within
social variables to allow monitoring by health professionals, and community‐based suicide prevention interventions that aim to
anticipated that approximately 18% of their cohort would present at reduce suicide among adults. The study findings show that most
baseline with suicide ideation. They go on to report that these included studies were qualitative (or were mixed methods including a
measures would be repeated at two annual follow‐up interviews and qualitative element), aiming to elicit the perspectives and opinions of
anticipated a reduction in depressive symptomatology and suicide service users to inform the design and development of community‐
ideation and behaviour. Cheng et al.50 report that participants gained based suicide prevention interventions. Few studies reported
improved web‐based suicide literacy skills. Zealberg et al.47 provide quantitative findings.
case studies to illustrate how three lives were saved by their The rationale for why and how a co‐productive approach was to be
emergency crisis support team intervention. Richardson et al.40 found implemented was mostly explained (e.g., to elicit stakeholder perspectives
no significant change in self‐esteem, depression and resilience in their to inform intervention development). However, some studies omitted a
‘Mind Yourself’ suicide prevention intervention. However, they report clear definition of the nature of co‐production applied. This finding is
gaining a valuable understanding of barriers related to procedural consistent with the literature, where an agreed definition of co‐
aspects of intervention delivery including extending the programme production is yet to be determined.2,17,18 As a result, the concept of
duration and the need to consider literacy levels among the target co‐production is interpreted to mean different forms of activities,
population. Lastly, four studies evaluating a suicide prevention commanding different levels of involvement, responsibility and resources
intervention specifically for men assessed pre‐ and postintervention within shared decision‐making that are couched under the umbrella of
38,41–43
changes using the CORE‐OM clinical assessment tool. co‐production.16,18,19 This points to a wider issue within the field of
co‐production research as a lack of consensus in how to define co‐
production means there is no clear metric against which to evaluate the
3.4.1 | Mechanisms of behaviour change associated multilevel components of co‐production. Smith et al.13 argue that
with co‐production researchers should abandon efforts to define co‐production in favour
of embracing heterogeneity co‐production offers within research and
None of the included studies explicitly identify the mechanisms of instead provide a contextually specific definition suited to their research
behaviour change associated with the inclusion of co‐ objectives. Others echo this and go further by advocating the
production. Subsequently, it is impossible to determine whether abandonment of the pursuit for a gold standard definition of co‐
any potential behaviour change related to suicide and/or mental production arguing that different approaches are needed to allow
health can be definitively attributed to the inclusion of co‐ tailoring of the co‐productive approach to suit the context in which it is
production. Nevertheless, all studies link reported outcomes to implemented.57 Instead, they urge researchers to be more reflective upon
positive changes engendered by engagement in the suicide preven- their application of co‐productive approaches and be more explicit in their
tion intervention such as self‐monitoring of mood/well‐being,48 reporting to overcome issues associated with poor operationalization of
improved help‐seeking,39–42,45,46,48–50 rapid access 41–42,44–48
and co‐production.57 Indeed, co‐production has been applied across different
improved coping strategies.38–42,45,46,48–49 health‐related contexts including mental health.58 However, it is
Most studies do not specifically report on the theory under- important for researchers to identify distinct measurable components
pinning suicide prevention interventions, despite a wide range of of the co‐production approach used to facilitate the evaluation of any
techniques being used to reduce suicidality. Four studies describe potential outcomes associated (i.e., you need to know you are evaluating
three models of suicide underpinning the suicide prevention to evaluate it).2
38,41–43 52
intervention, namely, the interpersonal theory of suicide, Involvement of stakeholders from diverse disciplines and back-
the collaborative assessment and management of suicidality53 and grounds, and the collaborative working relationships formed were viewed
the integrated motivational–volitional theory of suicide.54,55 How- as positive. Iterative discussions between stakeholders were the lynchpin
ever, these studies each focus upon evaluating the same suicide to the success of this collaborative working partnership, giving voice to
prevention intervention, the James' Place Model. Similarly, Hetrick stakeholders in shaping the suicide prevention interventions. Equity
et al.48 link the functionality of the content of their mApp to within collaborative working partnerships in co‐production is the
Dialectical Behavioural Therapy and Thorn et al.51 relate features of cornerstone of this approach.11,34,59 Yet, resistance from some research-
their #chatsafe to the resilient‐focussed Papageno effect. In addition, ers, developers and clinicians towards relinquishing power was evident.
while not explicitly theory‐based, Buus et al.'s49 mApp and the safety For example, a software developer in Thorn et al.'s51 study included a
39
planning intervention used by Ferguson et al. are based upon safety feature despite the users explicitly expressing that they wished for
Stanley and Brown's56 safety planning tool. this feature to be omitted. This power differential is common within the
20 | HANLON ET AL.
co‐production literature59–61 and can lead to tokenistic approaches in co‐ databases were limited to title searches that may have led to some
production‐based research.59,62,63 Redressing power imbalances is studies being inadvertently omitted.
important for promoting a culture that empowers stakeholders,
particularly service users, to share their knowledge. Failure to do so risks
undermining equity within the collaborative relationship, leading to 4.1 | Implications for policy and practice
professional knowledge being prioritized over lay knowledge.63 However,
methods to integrate key values of co‐production to avoid potential The present review findings provide some evidence that co‐
pitfalls, including power in‐balance, have been proposed (e.g., production can work in practice to engender positive outcomes.
INVOLVE).10 However, a lack of universal definition and established model for co‐
Within this review, participants' preferences of intervention content production implementation may pose some problems when creating
challenged researchers' and clinicians' preconceived ideas of what policy and practice guidance for the implementation of co‐
intervention elements should be included (e.g., Hetrick et al., study).48 A production within suicide prevention interventions. For example, different
shift away from ‘one size fits all’ approaches in suicide prevention modes and levels of stakeholder involvement in co‐production activities
27,64
interventions towards a tailored approach has been called for. Co‐ were evident within the included studies, but their involvement was
production offers an opportunity to work with the individual to identify predominantly limited to the co‐design aspect of the intervention.
and address their unmet needs in developing a tailored intervention Stakeholder involvement generally did not extend to other stages of the
approach to suicide prevention. Research evidence supporting the research process. This finding has been reiterated in other reviews within
implementation of a co‐productive approach within service design and a health‐related context,58 including suicide prevention.67 Inclusion of
delivery of a suicide prevention intervention is emerging. This is stakeholders within the research process before implementation of
highlighted by studies involving the James' Place Model, which aims to suicide prevention intervention may allow tailoring of the intervention to
support men experiencing suicidal crisis and has been found to suit a specific service user's needs and preferences.67 Yet, exclusion
significantly reduce suicidal distress.38,41–43 Relatedly, participants in beyond these formative stages removes the stakeholder from decision‐
39
Ferguson et al.'s study noted the value of co‐creation in formalizing making processes that may be pertinent to implementation aspects of the
personalized safety planning with their clients for the recognition of suicide prevention intervention (e.g., delivery and intervention evaluation
unique triggers of distress and coping strategies to mitigate this. and impact).67 Co‐produced related outcomes are often context‐
The focus of this review was upon co‐production within community‐ specific.57 Therefore, involvement of stakeholders within the latter stages
based suicide prevention interventions for adults. Several papers of the research process, including the evaluation of research findings, is
identified within the search referred to mobile app or online suicide warranted.67 This could prevent tokenistic involvement of stakeholders
prevention interventions. The authors determined it to be appropriate to by legitimizing the translation of their knowledge and expertise into
include these studies as technological advancement towards web‐/app‐ research evidence that meets the intervention objectives, and the
based suicide prevention highlights a new, burgeoning community that creation of evaluation approaches that measure meaningful impacts
warrants further research to understand the potential effectiveness of associated with co‐produced suicide prevention interventions.67
these types of interventions. Web‐/app‐based suicide prevention could
facilitate rapid access to support for individuals experiencing suicidal
crisis. However, increased accessibility may add an additional burden to 4.2 | Implications for future research
those who monitor such interventions as highlighted by some included
studies (e.g., Hetrick et al., study).48 Additionally, the very nature of web‐/ Future research should clearly define how co‐production is imple-
app‐based suicide prevention interventions requires users to have the mented and formally evaluate corresponding outputs from co‐
relevant access to technology to support their ability to access such production in the delivery of suicide prevention interventions. This
interventions. Therefore, whilst web‐/app‐based technology provides a is important for understanding the impact on potential outcomes, if
conduit for remote delivery of rapid suicide prevention intervention, it any, associated with a co‐production approach. While it is likely that
also may further widen health inequalities for the most vulnerable there are wider impacts associated with co‐produced community‐
65,66
including those of low socioeconomic status and the elderly. based suicide prevention interventions, further research is needed to
A key strength of this review was the broad inclusion criteria used understand the theoretical components of co‐produced community‐
to capture multiple modes of co‐production implementation (e.g., co‐ based suicide prevention interventions. This would allow for the
design, co‐create, co‐production). Second, the PRISMA reporting development of validated evaluation measures that can determine
guidelines have also been followed. Thirdly, a second reviewer has the intervention effects on suicide.
been involved during each phase of this review, thus reducing risk of While some positives were reported for the inclusion of co‐
bias within the results. The findings of this review should be interpreted production in community‐based suicide prevention interventions,
with caution due to the small number of included papers, inclusion of particularly from the perspective of participants, there is some
only papers published in English and the homogeneity of the study evidence that some professionals (e.g., clinicians) are reticent to
populations (i.e., westernized populations). Last, while multiple modes of relinquish their paternalistic roles. Future research should seek to
co‐production were included in the search criteria, the searches of understand the views/perspectives of those implementing co‐produced
HANLON ET AL. | 21
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review of suicide prevention interventions involving multisectoral

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13697625, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hex.13661 by University of Hong Kong, Wiley Online Library on [29/12/2022].

Evaluating the role and effectiveness of co‐produced

Claire A. Hanlon MSc, PhD Student | David McIlroy PhD, Reader |

School of Psychology, Faculty of Health,

Health Expectations. 2022;1–23. wileyonlinelibrary.com/journal/hex | 1

1 | INTRODUCTION The principles of co‐production are congruent with tailoring

2.1 | Eligibility criteria 2.3 | Search terms

Four electronic databases (PsycINFO, CINAHL, MEDLINE, Web of

Design and methods (inc. measures Quality

Design and methods (inc. measures Quality

Suicide risk/behaviours assessed

Design and methods (inc. measures Quality

Design and methods (inc. measures Quality

psychological, motivational and

Design and methods (inc. measures Quality

volitional factors (e.g.,

Design and methods (inc. measures Quality

were not routinely given for the

TABLE 2 Intervention characteristics

Co‐production and/or suicide‐related

Co‐production and/or suicide‐related

and public comments. Some

Co‐production and/or suicide‐related

and co‐creation safety planning

Co‐production and/or suicide‐related

building confidence, taking control involved local youth leaders as ‘co‐

Co‐production and/or suicide‐related

Evaluation of CORE‐OM scores

Co‐production and/or suicide‐related

(e.g., a researcher accompanied

Co‐production and/or suicide‐related

promote modelling of alternative

18. Nabatchi T, Sancino A, Sicilia M. Varieties of participation in public https://neweconomics.org/uploads/files/ca0975b7cd88125c3e_

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