Patterns and Risk Factors for Suicide Ideation Among In-school Adolescents in Nigeria and a Comprehensive Suicide-behavior Prevention Intervention Pilot Study

The effect of comprehensive suicide behavior prevention intervention among in-school adolescents Nigeria: a stepped-wedge cluster randomized trial

This study aims to evaluate the feasibility and effectiveness of a theory-based comprehensive suicide behavior prevention intervention among in-school adolescents in the Ikenne local government area (LGA) of Ogun State, Nigeria. The methodology of the study is a Stepped-wedge cluster-randomized trial of a suicide behavior intervention among fifteen secondary schools in Nigeria. The study chose the stepped-wedge design because although the investigators expect the intervention to reduce suicidal ideation, the feasibility of a full implementation may be challenging due to political, logistical, and ethical constraints. The design fulfills a secondary role of serving as a scientific tool to incorporate a fair method to determine the order of intervention rollout under logistic impediments. The implementation of our intervention is feasible only at the cluster level.

Investigators will conduct a Stepped-Wedge Cluster Randomized Trail among 15 secondary schools over one year. The participating schools will cross in a one-way switch over from the control to the intervention period. The sequence of switch over for the clusters will follow a stratified randomization scheme. All the schools will receive the intervention by the end of the study. All the groups will be recruited at the study onset and will act as control until the point of randomization into the intervention group. To mitigate contamination, the study will provide clear information on the purpose of the research to the participants. The clusters will get the details of intervention at the point of switching into the experimental group. The study will educate the intervention group against contamination. Also, the investigators will assess the exposure of the control group to the intervention before switching them. The study will report the level of contamination.

The study will recruit 15 secondary schools with a minimum of 100 enrolled students and do not have an existing suicide behavior intervention program. The school boards need to approve participation. Eligible students should be aged 10-19 years, give consent, and not have plans of leaving the school in the next year. Parental/guardians' assent is also a prerequisite for participation in the study. The study will not exclude non-participating students from the delivery of the intervention. The study will randomly select, by balloting, Five (three publicly and two privately-owned) schools in each of the three areas of the LGA. The selection of students will follow a probability sampling method. Eligible schools will be randomized into three sequences of five schools each, using a computer-generated stratified randomized sampling scheme. The stratification, which will be according to the area and ownership of the schools, will be supervised by the PIs. The nature of the experiment and intervention makes blinding unrealistic. However, investigators will ensure the conduct of the measurement of the study outcome objectively.

The intervention is a four-pronged comprehensive suicidal behavior prevention intervention in schools. The prongs consist of evidence-based interventions that use the Social Ecological Model (SEM). The SEM theorizes that there are multiple inter-related levels of influences on human behavior, and a successful preventive program should address factors at each stratum. The intervention addresses three levels; individual, interpersonal, and social. Firstly, the research will collaborate with relevant stakeholders to design and obtain a commitment from the schools to a suicidal behavior prevention policy and protocol document. Secondly, the intervention will train staff and students on best practices to improve students' connectedness thereby, creating a positive school environment. Thirdly, the study will identify and train gatekeepers on the proper response to suicidal thoughts and other suicidal behaviors; and serve as the link between the students and a school-linked mental health specialist. The research will train the gatekeepers to use school-based screening tools. Lastly, this research will educate all students on suicidal behaviors.