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Published on 24.11.2020 in Vol 9 , No 11 (2020) :November

 Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/19112, �rst published April 04,2020.

Family Members’ Perspectives on Family and SocialSupport Available to Suicidal Patients, and HealthSystems’ Interactions and Responses to SuicideCases in Alberta: Protocol for a QuantitativeResearch StudyRabab M Abou El-Magd 1 ;  Liana Urichuk 2 ;  Shireen Surood 2 ;  Daniel Li 2 ;  Andrew Greenshaw 1 ;  Mara Grunau 3 ;  Laureen MacNeil 4 ;  Ione Challborn 5 ;  David Grauwiler 5 ;  Robert Olson 3 ;  Vincent Israel Opoku Agyapong 1, 2

Article Authors Cited by Tweetations (1) Metrics

Abstract

Introduction

Methods

Results

Discussion

References

Abbreviations

Copyright

Abstract

Background:Suicide is a major cause of preventable death globally and a leading cause of death by injury in Canada. To support people whoexperience suicidal thoughts and behaviors and to ultimately prevent people from dying by suicide, it is important to understandindividual and familial experiences with the health care system.

Objective:We present the protocol for a study, the objective of which is to explore how people who died by suicide, and their family members,interacted with the health care system.

Methods:This is a quantitative research study. Data will be collected through a self-administered paper-based or online survey of the familymember of patients who died by suicide. The sample size was calculated to be 385 (margin of error ±3%).

Results:Data collection will start in October 2020 and results will be available by March 2021. We expect the results to shed light on theexperiences of individuals who died by suicide and their family members with the health care system. The study has receivedethical clearance from the Health Ethics Research Board of the University of Alberta (Pro00096342).

Conclusions: 

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Our study may inform practice, policy, and future research. The �ndings may shape how members of the health care systemrespond to people who are at risk of suicide and their families.

International Registered Report Identi�er (IRRID):PRR1-10.2196/19112

JMIR Res Protoc 2020;9(11):e19112

doi:10.2196/19112

Keywords

suicide in Alberta (1); suicide (30); family members’ perspectives; social support (49); health systems interactions (1) 

Introduction

Background

Suicide is a serious global public health problem, with an estimated 800,000 people reported to die by suicide every year [ ]. InCanada, suicide remains the 9th leading cause of death and the second leading cause of death among children, youth, and youngadults [ ]. Suicide impacts people of all ages and backgrounds in Canada. Every day, an average of more than 10 Canadians die bysuicide. There are close to 6000 emergency department visits and 2000 hospitalizations every year for self-in�icted injuries [ ]. Forevery person lost to suicide, many more experience thoughts of suicide or suicide attempts. For every death by suicide, a large circleof survivors are signi�cantly affected by the loss. Each suicide results in 135 people exposed (ie, who knew the person), who mayneed clinician services or support following exposure [ ].

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There were 4000 suicides in Canada in 2018 [ ], with more than 500 of these deaths occurring in Alberta. Suicide is consistently aleading cause of death among Albertans. Suicide claims more lives annually than other causes such as motor vehicle collisions andhomicides. Over 75% of those deaths occur among men, most between the ages of 30-69 years [ ]. Health care systems play a vitalrole in suicide prevention. One study in Alberta, for instance, found that the majority of people who died by suicide used a healthservice in the year prior to their death. They were also more likely to use the emergency department, in-patient services, orcommunity mental health services than those who died from other causes; they typically used health services for mental disordersas well [ ].

In Alberta, which is the site of this study, suicide prevention initiatives, including Living Hope, are underway to enhance aspects ofthe health care system, as evidenced by the Implementation Plan for the Edmonton Suicide Prevention Strategy [ ]. Living Hopepromotes a comprehensive preventative approach that seeks to enhance access to the protective factors that decrease the risk ofsuicide. The implementation plan upholds the inherent value of every person and recognizes that residents of Alberta, both asservice providers and as community members, can offer the compassion, respect, and hope needed to increase resilience andnurture hope for those contemplating suicide [ ].

The Mental Health Commission of Canada, in collaboration with the Canadian Association for Suicide Prevention, the Centre forSuicide Prevention, the Public Health Agency of Canada, alongside an Advisory Committee comprising people with lived experiencerelated to suicide, have developed toolkits to support individuals who have been impacted by suicide. One toolkit is tailored forpeople who have attempted suicide, and the other is focused on resources for people who have lost someone to suicide [ ].

Beyond stakeholder engagement [ ] and an understanding of the dimensions of service quality [ ], little is known locally about thepersonal, family, and social circumstances of people who died by suicide in Alberta. Similarly, little is known about how individualswho died by suicide and those close to them experienced the health care system. The current mechanism by which Alberta HealthServices (AHS) investigates suicide is through the Quality Assurance Review (QAR). A QAR of an adverse event utilizes the SystemsAnalysis Methodology, which aims to determine what happened, how it happened, and what can be done to improve care for futurepatients. This type of review generally involves engaging a multidisciplinary team to examine all of the health care systemcomponents (eg, environment, task, policy, etc) as they relate to an event (or group of similar events). This process often results inrecommendations aimed at improving the quality and safety of health care delivery. The focus is on improving structures,processes, and/or practices within AHS [ ]. QARs are done following a suicide on a case-by-case basis, and the results are notshared beyond those directly involved. The privacy of the QAR limits case comparison and knowledge translation. Additionally, anunderstanding of the context of death by suicide is needed, as it is thought to differ from the context of a suicide attempt. QARsusually focus on the health systems’ contributions to the suicide and do not place much emphasis on examining the personal,familial, and societal factors that also contribute to deaths by suicide. One study found that while individuals who attempt suicidegenerally exhibited similar levels of depression, those who died by suicide were signi�cantly more likely to have experiencedsigni�cant job stress and �nancial problems, left a suicide note, and used alcohol and drugs prior to the act [ ]. AHS is committedto patient- and family-centered care [ ], which highlights the importance of talking to families about both their own and theirrelatives’ experiences with the health care system. Ultimately, insight into the experiences of people who died by suicide, and theirfamily members, has the potential to inform policy and practice, and shape how members of the health care system, and AHSspeci�cally, respond to individuals who are at risk of suicide.

Objectives

The purpose of this study is to understand better the family and social circumstances of individuals who died by suicide, and howthose who died by suicide and their family members interacted with the health care system. This study extends the knowledge to begained from a recently completed qualitative study that examined family members’ perspectives on health system interactions withthose who died by suicide [ ].

Our speci�c quantitative research questions are:

1. What factors related to family, society, and health systems contribute to death by suicide in Alberta?

2. How do individuals impacted by the suicide of a family member perceive their own interactions with the health care system?

To the best of our knowledge, no previous province-wide study has examined the personal, familial, societal, and health systemsfactors that contribute to suicide deaths in Canada. One study was conducted by Schaffer et al [ ] to investigate the population-based analysis of health care contacts among suicide decedents prior to death by suicide. It was a systematic extraction of datafrom records at the O�ce of the Chief Coroner of Ontario of each person who died by suicide in the city of Toronto from 1998 to

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2011 [ ]. Consequently, this work, the �rst of its kind in Alberta and in Canada, could help identify important factors that areassociated with deaths by suicide in the province of Alberta.

Methods

Study Design

This study utilizes a quantitative research design. Data will be collected through a self-administered paper-based or online survey ofthe family members of patients who died by suicide ( ). A sample size of 385 was predetermined on theassumption that with an annual average of 500 people dying by suicide in Alberta, a 95% CI, and one family member per suicidedecedent completing the survey, the sample size needed to estimate family members’ perspectives on health system interactions,as well as family and social support for suicidal patients, with the margin of error ±3%, is 385. Data will be collected via both paperformat and online. Prospective participants will be provided with paper-based or online information lea�ets.

Participants

Participants will be adults; they should also have a close family member who has died by suicide in the previous 12 months and hadregular contact with this family member prior to their suicide, such that they are reasonably aware of their personal, family, andsocial situation prior to their suicide as well as their interaction with the health care system. Participants do not have to identifythemselves and their submission of the survey implies their consent.

Data Collection

We initially designed a survey form that re�ected risk factors for dying by suicide identi�ed in the published literature as well asadditional factors to help answer our research questions. The draft survey questions were reviewed by the Canadian Mental HealthAssociation (CMHA), Alberta Division, and the Centre for Suicide Prevention, and changes were made based on the feedbackreceived. The survey was then pretested on two volunteer family members of patients who had died by suicide before being furtherrevised and �nalized for use in the study. The survey questions take 10-55 minutes to complete, and no incentives will be offered toparticipants who complete the survey. Paper-based recruitment will be done in collaboration with the CMHA regional o�ces inAlberta. The association runs focus groups for family members of people who died by suicide, with hundreds of people attendingannually. Information lea�ets and posters advertising the study will be distributed among prospective participants attending thesefocus groups. Those interested in participating in the study will be provided with guidance on how to access the survey questions.

In addition, online versions of the survey will be promoted through the websites and social media feeds of AHS, the CMHA, theCentre for Suicide Prevention, the Edmonton Mental Health Foundation, and the University of Alberta’s Faculty of Medicine andDentistry. The online survey is designed in accordance with the CHERRIES (Checklist for Reporting Results of Internet E-Surveys)checklist [ ]. Prospective participants will be invited to review the online version of the information lea�et and proceed to completethe survey. Information identifying participants will not be collected for the online survey, and completion and submission of thesurvey denotes consent. The study will be conducted in accordance with the Declaration of Helsinki (Hong Kong Amendment) andGood Clinical Practice (international guidelines). Informed consent will be obtained from each participant. The study has receivedethical clearance from Health Ethics Research Board of the University of Alberta (Pro00096342).

Data Analysis

Quantitative data will be analyzed using SPSS, version 26 (IBM Corp), using descriptive statistics and correlational analyses [ ]. Achi-square test will be used to explore differences in responses between demographic variables of the suicide decedent and therespondent.

Results

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Multimedia Appendix 1

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Data collection is expected to commence in October 2020. Results will be available by March 2021. Findings from the study willhelp illuminate factors related to family, society, and health systems, and the role they play in death by suicide in Alberta.

The study results will be disseminated at several levels, including to participants, practitioners, academics/researchers, and healthcare organizations.

Our team will plan an organizational engagement strategy to advance discussions about feasibility and effectiveness prior to theconclusion of the trial. This will help ensure the �ndings are a relevant part of decision-making processes. In addition, this mayfacilitate the planning of a larger study that is endorsed at both leadership and operational levels so that the potential bene�ts ofthe study results can reach participants in a timelier fashion.

Discussion

The main objective of this study is to investigate the familial, societal and health systems–based support available to individualswho die by suicide in Alberta. It also aims to examine the support offered by the health care system in Alberta to family members ofpatients who die by suicide.

Studies in other jurisdictions suggests that personal, familial, and social factors such as stigma [ ], public education [ , ],psychiatric illness [ , ], age [ , ], gender [ , ], marital status [ ], positive support [ , ], familial history of suicide [ – ],and alcohol consumption [ , ] are associated with death by suicide. Similarly, health system factors such as staff attitude towardsuicidal persons [ ], recency of hospitalization for suicide attempt and recent health care contact [ , , – ], underdiagnoses ofmental disorders and major depressions [ ], brevity of interactions with medical staff [ ], ignoring suicide-related warning signsby health care providers [ ], lack of trust in health care services [ ], and relatives’ feelings of exclusion from information ontreatment [ ] have all been positively associated with deaths by suicide in studies conducted in other jurisdictions. The results ofour study will provide us with information on familial, societal, and health systems–related in�uences in Alberta as well as aspectsof care in need of further improvement and re�nement. The recommendations arising from this study have the potential to lead tosigni�cant system enhancements and reductions in suicide rates in Alberta and beyond.

Acknowledgments

This study is supported by Alberta Health Services, the Centre for Suicide Prevention, and the Canadian Mental Health Association.

The authors received no �nancial support for the research, authorship, and/or publication of this paper.

Authors' Contributions

RMAE-M, contributed to the study design and drafted the initial and �nal versions of manuscript. LU, SS, DL, AG, MG, LM, IC, DG, andRO contributed to the study design and reviewed the initial and �nal drafts of the manuscript. VA conceived and designed the studyand contributed to drafting the initial and �nal versions of the manuscript.

Con�icts of Interest

None declared.

Multimedia Appendix 1

Quantitative research study survey.

DOCX File , 36 KB

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Abbreviations

AHS: Alberta Health ServicesCHERRIES: Checklist for Reporting Results of Internet E-SurveysCMHA: Canadian Mental Health AssociationQAR: Quality Assurance Review

Edited by G Eysenbach; submitted 04.04.20; peer-reviewed by E Kleiman, K Fox; comments to author 12.06.20; revised version received02.08.20; accepted 18.08.20; published 24.11.20

Copyright 

©Rabab M Abou El-Magd, Liana Urichuk, Shireen Surood, Daniel Li, Andrew Greenshaw, Mara Grunau, Laureen MacNeil, IoneChallborn, David Grauwiler, Robert Olson, Vincent Israel Opoku Agyapong. Originally published in JMIR Research Protocols(http://www.researchprotocols.org), 24.11.2020. 

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Abou El-Magd RM, Urichuk L, Surood S, Li D, Greenshaw A, Grunau M, MacNeil L, Challborn I, Grauwiler D, Olson R, Agyapong VIOFamily Members’ Perspectives on Family and Social Support Available to Suicidal Patients, and Health Systems’ Interactions andResponses to Suicide Cases in Alberta: Protocol for a Quantitative Research StudyJMIR Res Protoc 2020;9(11):e19112doi: 10.2196/19112PMID: 33231553PMCID: 7723743

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This paper is in the followinge-collection/theme issue:

RCTs – Protocols/Proposals (eHealth) (384)

Depression and Mood Disorders; Suicide Prevention (991)

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JMIR Research Protocols ISSN 1929-0748

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1/23/23, 9:14 PM JMIR Research Protocols – Family Members’ Perspectives on Family and Social Support Available to Suicidal Patients, and Health Systems’ Int…

https://www.researchprotocols.org/2020/11/e19112 9/9

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