KhonKaenRajanagarindraPsychiatric Hospital

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
During the past 45 years, 60% of the countries around the world have had a rising rate of suicide. The World Health Organization (2009) indicates that approximately 1 million people die of suicide annually, or on average 1 person commit suicide in every 40 seconds, while there were 10-20 million cases of attempted suicide and will be 1.5 million cases in 2020. For Thailand, in 1999 the suicide rate was 8.59 per 100,000 people, highest in 10 years round. The numbers of people who tried to commit suicide have been increased continuously during 1997 to 2001. It related to situation of world economic crisis in 1997 (Office of Policy and Strategy, 1999). An epidemiological study by KhonKaen Rajanagarindra Psychiatric Hospital on attempted suicide behavior revealed that there were 25,000 – 27,000 cases of attempted suicide per year, and 4,500 – 5,500 people died. On average 14 people died of suicide daily. Males were 3 times higher rate than females. Most of them age between 20 – 39 years old. Farmers and laborers made up the highest number of suicide. Their co-problems were chronic diseases, psychiatric diseases, drank alcohol and drug abuse. Persons who tried to commit suicide took 24 – 72 hours for making decision to do so and it was unpreventable (Apichai Mongkol, et al., 2003). Analysis of the data obtained from interviewing persons with attempted suicide, health personnel and health services management revealed significant problems and limitations as following: 1. Persons who attempted to commit suicide were unable to bear with social pressure, crisis, depression, disappointment, quarreled with intimate friend, found no way out, and unconscious to prevent attempt suicide. 2. Family members, neighbors and community leaders lacked of knowledge, understanding and attitude to prevent attempted suicide. They thought that it was an individual issue, unreligious, or trying to get attention. Therefore, they ignored the warning signs of attempted suicide. 3. There was no prevention and continuum of care system. The former system was only care/treatment after unsuccessful suicide. Knowledge and technology were un-unified, copied from other countries and not being in line with Thai cultures and traditions. 4. Health personnel lacked knowledge, skill and guidelines to take care of the cases resulting on lacking of referral system from and to community and continuum of care. The data obtained only showed the number of clientele and could not be used to solve problems in each area. Therefore, persons with attempted suicide received treatment for the symptom rather than the cause, so they repeatedly commit suicide and end up with lost their lives. Family member and the closed contact persons then felt guilty, became stigma, and turned to be a new case later on. Social and cultural changes, conflicts, natural disasters, etc. were risk factors affecting adjustment of persons to those situations. Therefore, it is very crucial to have an assistance system to support and prevent the problems.

B. Strategic Approach

 2. What was the solution?
Khon Kaen Rajanagarindra Psychiatric Hospital (JVKK), Department of Mental Health, as a regional psychiatric hospital of the Northeast responsible for 7 provinces: Khon Kaen, Roi Et, Maha Sarakham, Kalasin, Udon Thani, Nong Khai, and Sakon Nakhon, conducted a study on suicide prevention in Sakon Nakhon province. Sakon Nakhon had a sharp rise of suicide rate in 1999 (1.6 per 100,000 people higher than the rate in 1997, or 60 deaths out of 85 attempted suicide). Results of the study revealed that key success factors were integration of work among stakeholder concerned, realization of problem, creating community cooperation, on time screening of risk people and referring for services, and having surveillance system after the cases were referred back to community. National-Level Assistance System for Persons at Risk of Suicide” was developed and became a model to implement all over the country. Lesson learned was re-discussed in evaluation of the project that can be concluded as important concept as following: Creating collaboration and integration of works among persons involved with the problem from individual level, family, community, and health personnel level by observation, self-evaluation or evaluation of proximal person, paying attention to warning signals, knowing service resources in neighborhood, referring system and caring of risk group. Development of the integrated service system that linked with community: The service units were developed to serve those who failed to commit suicide according to standard and guidelines. Patients who went back to community would be evaluated, followed up, and continuously monitored by making appointments and home visits until the cases were safe from re-commit suicide. The services also include outreach services to screen high risk group for early prevention. Development of accurate and reliable suicide database of Thailand to be a warning system which categorized severity level, risk group, risk factors, stimulating factors and showed movement of problems. The data were used in decision making of administrators, setting strategy and indicators. In addition, data were used to plan appropriate activities for target group and to develop curriculum for training health personnel and other groups. Development of knowledge and technology continuously for health personnel and various groups. It should be written in the local language and designed for self-study in e-book. Furthermore, epidemiological study on self-harm behavior, causes, risk factors and protective factors was used to develop curriculum for personnel development. Periodically evaluation of users is needed for content improvement. Continuously building capacity for personnel inside and outside the Ministry of Public Health in terms of training of trainers for provincial personnel, refresher them annually to be resource persons in training and counselling through electronic system in the province, and develop guideline to be standard of practice for each profession. Movement to create mechanism to solve suicide problem at national level was made to reflect problem to society, create awareness and participatory problem solving. Social risk factors associated with suicide were reside with people with drug addiction/ alcohol consumption, law on occupying of weapon, controlling on use of chemical/insecticide, receiving information on suicide, and lacking of social support mechanism.

 3. How did the initiative solve the problem and improve people’s lives?
Assistance System for Persons at Risk of Suicide (ASPRS) is a project to change the way of thinking, attitude and working methods. This is a proactive working to protect and assist those who are at risk of suicide instead of old fashion treatment. Creating a system to assist persons who are at risk of suicide is a process of managing problems. To solve the problems need cooperation of all parties. Persons involve with the problem will be owners of the problem. Knowledge and technology were developed based on fact that occurred in Thai society and were adjusted to apply in each area according to languages and cultures. People have knowledge on self-care, have self-assessment tool on risk of harming themselves. Family and community recognize warning signs before the loss occurred and be able to help people who are at risk of suicide get fast access to the service. Public health posts are able to help target group in their areas effectively. Furthermore, database and reporting system acts as a Warning System enable all parties to know current situation and movement of the problems that can be used to set national policy and strategies suitable for each level. ASPRS is not Jobs by role. It is made with love, good wishes appreciating humanity. With the right to live. Although the problem is not being dealt out to them all. But good rapport from the family and society network will encourage to their soul restored until the crisis has passed. ASPRS is a result of the cooperation of all sectors indeed.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The suicide prevention system has been developed for 13 years (1999 – 2012). Stages of development can be summarized as follows Phase 1 " Sakon Nakhon Model" (1999-2001): JVKK studied suicide problems in Sakon Nakhon by interviewing attempt suicide cases, their relatives, community leaders, and health personnel and found important obstacles of access to care and un-continuing of services. The result was used to develop a course syllabus and training handbook for nurses and health personnel. Workshop to exchanged best practices came out the report forms, data management care report and guidelines for health personnel and used as a pilot implementation in Sakon Nakhon province. Phase 2 “Expanding the project (2001-2003)” In 2001, Department Mental Health assigned JVKK as project manager expand this model to 33 provinces that had high rate of suicide from 4 regions of the country. JVKK collaborated with Khon Kean University to monitor and evaluate the project. The results showed needs for screening tools on suicide attempt. In 2003, JVKK developed surveillance report system on depression and suicide (DS 506). Phase 3 "Nationwide accessibility" (2004-2006) the Sakon Nakhon Model was used nationwide through provincial strategic plan. Every hospital reported surveillance in DS 506 form to provincial health office. Data from all provincial offices were sent to JVKK on line to analyze to be national suicide database. Severity of suicide problem showed to be problem and was defined as one of the Ministry of Public Health’s indicators since 2005. Phase 4 "Toward Sustainability (2007-2010)”: JVKK provided Geographical Information System (GIS) to support all Public Health Units by combining surveillance data and death certificate data in GIS. JVKK adjusted its’role on supporting and monitoring health service system. Suggestion from the field led to development of new depression and risk of suicide (DS 8), simplified version to use in community. Phase 5 “Turning point to national and international level”. (2010 - 2012) The main strategies were extending cooperation to the public sector and international organizations. The suicide problem was announced as one of the national agenda of 4th National Health Assembly's in 2011. International Learning Center was developed aiming to be leader of knowledge management, training in specific issue and exchange technical issues. The international co-operations with neighboring countries (China, Singapore, Hong Kong and Cambodia) were initiated in 2012. Phase 6 “ Excellence center Suicide” (2012 - present). Results from operating continuously. It is apparent to the feasibility and usefulness.The adoption Moreover, the country has formed a new work. To be integrated in And the Academic Unit. Serve academic support and development personnel to be ready to cope with the problem by themselves. Therefore,JVKK change the role of the executive management of the care system across the country. The agency has the expertise to develop a defense minister who tried to harm themselves . As a consulting and system design to ensure that the system remains. It also acts as the data analysis and in-depth research even more. Provide information to other agencies are ready and confident with the ability to cope with problems that may come back again.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The stakeholders involved in the implementation were: 1. The Department of Mental Health drove the policy and supported budget. JVKK was funded and assigned as a national project manager for analyzing problems, supervision, monitoring, evaluation and support the academic development. Mental Health Centers (MHCs) and Mental Health hospitals, service units of the Department of Mental Health in the region provided technical support, training, monitor and supervise community hospitals and health promoting hospitals. Community hospitals and health promoting hospitals provide services according to the standard. Khon Kaen Universities and Chaing Mai Universities were collaborated to develop standard service system which applicable for each area. 2. The provincial and district public health offices and local organizations involved in the process leading to the actual practice in the community by being trained to provide consultancy services, do home visit, report, collect data, analyze data and transfer the data. Hence the national database was established and reliable. 3. The evaluation for change was an important process. Community leaders, family and relatives provided feedback to improve the implementation in accordance with the actual situation through the provincial health network assembly coordinator. The Mental Health Centers were responsible for regional assessment, analysis and evaluation information. The JVKK was responsible for national evaluation and recommendation on prevention policy. 4. The Health Assembly, in the northern part of Thailand, is a process in which the relevant public and State agencies exchange their knowledge and cordially learn from each other through a participatory and systematically organized in 2011. So that the solution is comprehensive and meets the real needs of the people.
 6. How was the strategy implemented and what resources were mobilized?
Budget 1999-2000: model development stage. This was financially supported by JVKK internal revenue to promote education in Sakon Nakhon province. 2000-2012: expansion stage. This stage was financially supported by the bureau of the budget at the amount of 9.5-10 million baht annually. This budget was allocated according to annual strategy as followed: 1) campaign on knowledge dissemination to the public through various channels (10%); 2) human resource development for people in and out of the ministry of public health network including organizing trainings, seminars, and publishing training manuals (42%); 3) producing handbook, technology for public health personnel and community leaders (10%); 4) database and website ( development (16%); 5) research and innovation (22%). JVKK was responsible for financial management of the project. 2007: eight Northern provinces began the project using money from the local administration offices, provincial senior slubs, national health security fund and fund from mental health centers. 2008-2010: another twenty-five provinces followed suit, budget spending ranged from 169,000 to 248,370 for data survey, community leader training, and social support developments in the community. The activities were integrated to routine work of each province later on. Under the conditions of limited budget and change in social factors, it was necessary to analyze and search for the stakeholders and build up participation with diverse groups in the government sector, the private sector and the mass media sector. Technical Information technology has been fully implemented. Report was sent on line. Suicidal rate was classified according to its violence and was tallied based on Geographical Information System (GIS). Website has been developed to promote communication, support coordination and monitoring. The website also disseminates knowledge and technology among workers in the networks. JVKK took care of the IT system, updated knowledge, developed and produced tools and technology appropriated to target groups. Human resources 1) Development of health personnel: at least three health personnel (doctors, nurses, psychologists, and public health workers) from regional/provincial hospitals and community hospitals were selected for training on mental therapy, monitoring and supervision skill, data analysis, epidemiology research, curriculum writing, manual development, IT, and CPG process,. 2) Development of network outside the ministry of public health, five to ten people (community leaders, Tambon chiefs, village chiefs and local administration officers) were selected from each community for training on mental health and assessment of suicidal risk. In addition, we are in cooperation with Faculty of Medicine, Khon Kaen and Chaing Mai University for research development and contribution to the body of knowledge. Resource management Data and results were analyzed quantitatively and qualitatively. Public hearing was operated; annual operating plan was prepared accordingly. Expenses for each activity were calculated and human resource is managed following predetermined objectives and strategies. Operational and strategic meeting was organized so everyone involved understood objectives, goals, duties and ways to work together. Personnel at all levels got operation manual for implementation. Auditing is organized once a year to alleviate problems for province that found difficulty to follow details in the manual.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The achievement took place and was the main factor that can be used to predict success in the social problems of Thailand including by: 1. The development of human resources both in and out of the ministry of public health. 86.38% of health personnel were trained. In addition, on average 809 health volunteers and community leaders, 166 teachers and 100 nurses were trained. These personnel could handle the services from institution through community level. 2. Suicidal database of Thailand has established since 2007 covered 77 provinces. Public Health posts screened the case, identify and brought the case to health service system. Data was sent on line to JVKK every 6 months. JVKK analyzed data and compile to warning system and summarized annually to provincial mental network. 3. Development of integrated health system and access to community linkages. Clinical Practice Guideline (CPG) for medical personnel were used to provide standard and sustainable services. In 2012, all health service units all over the country set up solving of suicide problem as a provincial policy. 85% of attempt suicide cases were turned to home visit system, 82.5 % were in follow-up system. Campaign at national level was hold on 10th September each year. 4. Ongoing Development of knowledge and technology, divided into 4 groups: 1) instruments used to assess risk of suicide, 2) training course/program for physicians, nurses and community leaders to prevent a suicide, 3) Clinical Practice Guideline (CPG)for tertiary hospital, general hospital and community hospital, 4) suicidal prevention guideline for people. 5) Epidemiological researches about self-harm behavior of Thai population, during 2005 -2009 (2 studies per year). Moreover, 16 researches were published during 2007 – 2012, and 4 sets of E-Learning for health personnel were produced. The impact of implementation has been extended to all provinces in Thailand. The problem of the difference in geographical, cultural and living conditions requires that the driving mechanisms must be based on principles derived from the continued studies in each area. An extremely important point is having the database of each area that serves as a "warning system" that leads to re-processing capable of coping with the problems.

 8. What were the most successful outputs and why was the initiative effective?
1. The cooperation of individuals involved with the operation. The public health personnel take care of all self-harm persons with case management. Health personnel used surveillance report (DS 8) to follow up and refer the case. The report was record and sent on line. Every case will be protected by coding system. At provincial level, the report was compiled and sent to JVKK every 6 and 12 months. 2. Database of Suicide Thailand. Data sources from a death certificate by Ministry of Interior were coordinated with the Bureau of Policy and Strategy every 6 months. Since 2012, personnel from Khon Kaen Rajanagarindra Psychiatric hospital and Planning Division, Department of Mental Health are assigned to analyze and prove the accuracy of information together. 3. Integrated Service Systems Development and Community. Supervision and monitoring system. The supervisors composed of personnel from the Department of Mental Health and the Office of Inspector General, Ministry of Health. Every 6 months, these supervisors will supervise and monitor the results of help care system for attempt suicide at regional level and submit to JVKK every 6 and 12 months. At provincial level, representatives from mental health hospital and provincial health office were supervisors and supervised at 6th and 9th month of fiscal year. 4. Continuous Development and Technology. Every year around December, Khon Kaen Rajanagarindra Psychiatric hospital will survey about the demand for new knowledge, media and technology from the public health personnel. In addition, user who received e-documents or was supported by expert will be evaluated on the implementation of knowledge and technology used, either in paper form or via the website. 5. Human Potential Development, both inside and outside the Ministry of Public Health. Early in the fiscal year, questionnaires were distributed to network both in and outside the ministry to review potential development needs related to care of self-harm persons, knowledge transferring, potential development for training/seminars.

 9. What were the main obstacles encountered and how were they overcome?
Three problems in implementing the model are : 1. Health personnel, lack of knowledge Correct understanding,due to lack of knowledge and skills to treat persons who were at risk of suicide. Continuous meetings have been organized for personnel on searching method, screening and treatment of self-harm cases. Knowledge also can be accessed through E-Leaning. Seminars, sharing experience during supervision, and presentation of research/study in national meeting were means to increase knowledge and skills to personnel in the network. 2. Public attitudes that ignore the need to engage in problem solving . So, we readjusted the content and methods of campaign appropriate to target groups, production of interesting, but simple guideline for the public, bringing celebrities to be presenters of the campaign, and developing simple assessment tools to use in community. 3. Planning to prevent problems appropriate to each area. Because of the large area of operations, Language and cultural differences are factors involved. It is difficult to perform a task to accomplish in a short time, so we used the epidemiological studies. Reviews of knowledge and academic performance of multiple sources and evaluation of performance regularly can ensure completion of the works. The Khon Kaen Rajanagarindra Psychiatric hospital pushed the issue of suicide as public policy that all sectors, especially civil society should take the major role in dealing with the problem. The technical units of the Department of Mental Health provided technical support and promote the participation of the people involved in managing the problem

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Results of operations throughout the period of 13 years, benefits accrued to the involved area. 1. Successful reducing size of the problem for the whole country. The rate of suicide in the years 1999 to 2012 fell to 2.3 per 100,000 population. This could save life of 1,415 people from suicide each year. 2. Countries could reduce cost of care for self-harm patients and admit in psychiatric hospital on average 7.5 million baht per year. Despite of the economic crisis during 2008 -2009, the suicide rate still remains at 5.97 per 100,000 populations (2009). 3. Families, community leaders and the community were closely cooperated. A survey of the health personnel satisfaction on outreach mental health services, such as schools, communities, and factories, showed moderate satisfaction, 3.6 out of 5 points (Apichai Mongkol et al, 2007), and increased to 3.9 points out of 5 points in 2009. 4. Good co-operations of social networks. Khon Kaen Rajanagarindra Psychiatric hospital has expanded the network to civil society, health assembly: from provincial level (Chiengrai province) to regional level (Lanna Assembly). “Management of suicide problem" was announced as one of the national agenda of the 4th National Assembly in 2011. JVKK also works with Health Intervention and Technology Assessment Program (HITAP), medias such as radio, newspapers and television, including private sector (Samaritans Association) and to be a member of the International Association for Suicide Prevention (IASP). 5. Public Health Units have guidelines to assist health personnel. Persons at risk of suicide have been screening on average 120,238 -257,180 cases per year, or 3,340 cases per province (during 2007 -2009 ). 13.96% were found that they are at risk of suicide which was similar to prevalence rates of those with suicidal ideas and attitudes (17.6% of the general population). (Theinchai Ngamtipwatana and Suteera Patrathutawat,1999). For treatment and care: physicians could care the self-harm patients average 15.8 cases per year, did counseling to those who still alive from trying to harm themselves average 8.4 cases per year. For depression patients, it was likely to do counseling average 7.8 cases per year. And self-harm patient who hurt themselves will received a home visiting average of 2.5 - 3 times per case. As a results, the rate of self-harm more than 1 time reduced from 10.6 per 100,000 population in 2004 to 4.1 per 100,00 population in 2007. 6. A set of specific knowledge and technology. Forms of technology, starting from documentation, manuals, lesson plans, video, VCD and were developed into e-book that includes 18 stories. Reference from Statistic of E-Books’ viewing in 2009 showed that users were personnel health (24.94%), personnel of the Department of Mental Health (18.14%). On Satisfaction: it was showed that 58.51% were satisfied with good design of the web and 53.97% were satisfied with accessibility of the web.. Nurse and Public Health officers had confident to use counseling skills in moderate to good level. A confidence score was 3.6 points out of 5 points which was higher than the score in 2005 (3.5 points). Tools to assess depression and risk of suicide for public health personnel, community leaders, village health volunteer and individuals to use for self- screening or with closely person who were at risk of suicide were as following: 1) .Depression Screening Test, 15 questions, and Suicidal Screening Test, 10 questions. (in 2003) 2) Depression and Suicide Screening Test (in 2008), and 3. Suicidal Screening Test (SU-9) in 2010. 7. A "warning system" that leads to re-processing capable of coping with the problems. An extremely important point is having the database of each area for surveillance and analyst data to information and knowledge, which all level can use.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
The project has been implemented by the Department of Mental Health from 1999 to 2012 by allocating of budget on research, development of model, expanding to all over the country, and propelled to be KPI at the Ministry level. As a result, surveillance system on depression and self-harm was initiated and the rate of suicide could be reduced to be at 58th rank of the world and still be at 5.9 per 100,000 population. (2007-2010) The continuous of services, follow-ups and care given to persons who attempted to commit suicide, 97.53-97.60% of the cases were took care from 2010 to 2012. Result of integration of the service into routine works of public hospitals and communities, the Department of Mental Health could reduced budget allocation by half in 2011 (from 10 million Baht to 5 million Baht) and to zero support in 2013. In the provinces with the suicide rate in the top 10 ranks, the action plan aimed to extend the provincial model to cover the local level, having the provincial trainer to transfer knowledge and use the existing technology to develop the potentiality of personnel. For examples, in 2013, Rayong province held a workshop to introduce the guidelines for care and help those who were at risk of suicide. In the upper northern areas, such as Chiangrai and Lampoon there are suicide prevention campaigns in the community. Modern information technologies were used as channels of coordination with the clients and the health service network. In the conference of the network, Skype was used and the members were able to communicate immediately. In addition, modern technologies were used as channels for learning and counseling. In case of a patient with complex problems, VDO conference was employed, and decisions can be made more rapidly by saving time and expense. JVKK has changed its role from the project manager to be an academic supporter and has developed itself to be a center of expertise, “Excellence Center,” in order to be a training center for medical and nursing personnel. Development and training programs on specific knowledge and technology for health personnel have been conducted continuously such as the curriculum of physicians specialized in mental health and psychiatry, and the specialized curriculum of psychiatric and mental health nursing.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Thirteen years of continuing of works, it can count that it is a valuable work that could help people who have no way out to continue their lives. The developed model was expanded and used all over the country that could reduce lose of family and the country. A very important point is pushing the suicide problem to be solved in the national-policy level and all of the administrators give high priority to suicide prevention operation, empower the morale and confidence, and are determined to go forward even less budget is allocated for the organization and the suicide rate does not exceed the limit. Nevertheless, the situation of structural change of the family, the way of life and the living conditions, transferring of social and cultural concepts, technological progress, difference of the causes of problems in each age group, and convenient access of weapons, are all sensitive issues and they keep warning that the recurrence of the problem is always possible. We believe that “Suicide” is not a “disease”, but it can be prevented with confidence on the concept of “ STOP ” as the driving mechanism as follows: S - System: Having a model and approaches that explicitly link care between health service unit and the community, T - Team and Technology: Teamwork with one same heart, working as a collaborative network ,and the support of modern technology O – Ongoing: Working continuously with no pause and with clear-cut goals P – People: Realizing the importance of groups of people who involved in the work. Furthermore, from reviewing the limitations of the work, the importance issues are: 1. Preventing access to dangerous weapons or objects used as tools easily: such as a gun, pesticide, alcohol or prescription drugs. 2. Ethics of the pubic-media or in presenting news about the suicide regardless of the impact of content to reinforce stigma to the family survivors of suicide and may imitation the behavior of others. 3. Family is important that people make the decision to self-harm. When reviewing the past found that families Thailand still has gaps. There is a lack of communication between family member.

Contact Information

Institution Name:   KhonKaenRajanagarindraPsychiatric Hospital
Institution Type:   Government Agency  
Contact Person:   Mr. Sakarin Kaewhao
Title:   Deputy Director  
Telephone/ Fax:   +(66)43 209999 / +(66)43 224722
Institution's / Project's Website:  
Address:   169 Chadapradungroad
Postal Code:   40000
City:   MuangKhonKaen
State/Province:   KhonKaen

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