This research article, titled “The Role of Contextual Determinants in Implementation of Complex Suicide Prevention Interventions: An Application of the Exploration, Preparation, Implementation and Sustainment (EPIS) Framework,” was published in The International Journal of Health Planning and Management. Authored by Sadhvi Krishnamoorthy, Gregory Armstrong, Victoria Ross, Sharna Mathieu, and Kairi Kõlves, the paper was received on April 7, 2024, revised on December 31, 2024, and accepted on February 3, 2025.
The article addresses the growing complexity of public health issues, particularly suicide prevention, which accounts for approximately 700,000 lives annually. While effective interventions exist, their adoption, delivery, and sustainment within real-life settings prove challenging, with the translation process often overlooked. This study underscores the critical need to examine the impact of “context” to understand how implementation outcomes are achieved and to facilitate the generalizability of findings. Context is defined as “a set of circumstances or unique factors related to the setting or community that surround a particular implementation effort”.
The primary aim of this research is to explore factors influencing implementation outcomes, specifically contextual determinants, across the entire lifecycle of complex suicide prevention interventions. By doing so, the authors seek to understand how both external (outer context) and internal (inner context) factors influence the delivery, adoption, and sustainment of these interventions, ultimately explaining why an intervention was (in)effective.
To achieve this, the study adopted a qualitative design, conducting semi-structured interviews with 16 global stakeholders (leaders, project managers/implementors, and lived experience advocates) involved in suicide prevention. A purposive and snowball sampling approach was used to ensure diverse perspectives. The collected data underwent thematic analysis, with emergent themes then mapped onto the Exploration, Preparation, Implementation and Sustainment (EPIS) framework. This framework was chosen for its utility in understanding both implementation processes and determinants across multiple socio-ecological levels and phases.
Key findings indicate that outer context barriers were predominantly reported across all phases of implementation, often related to service environmental factors such as pervasive mental health stigma, treatment gaps, and a lack of service system integration. Inner context barriers, including issues with individual characteristics (e.g., sustaining motivation) and inadequate staffing and resources, were primarily observed during the implementation phase. Importantly, the study identified “bridging factors,” such as interrelationships, partnerships, and community engagement, as crucial facilitators throughout different implementation phases and across all levels of context. These bridging factors were described as the “connective tissue” between outer and inner contexts. Furthermore, implementation strategies focused on stakeholder relationship building were prioritized across various phases.
In conclusion, this study significantly expands the understanding of the evidence-base for complex suicide prevention interventions by illuminating determinants across different levels of social ecology and phases of implementation. It provides valuable insights into what works and under what circumstances, emphasizing the critical role of contextual understanding and the importance of bridging factors. The research also highlights existing gaps in planning for the sustainability of interventions, advocating for improved future planning and transparency in this area. The findings are intended to assist in identifying effective implementation strategies to overcome barriers and enhance facilitators, thereby contributing to future implementation efforts based on practical experiences.
Reference: Krishnamoorthy, S., Armstrong, G., Ross, V., Mathieu, S., & Kõlves, K. (2025). The role of contextual determinants in implementation of complex suicide prevention interventions: An application of the Exploration, Preparation, Implementation and Sustainment (EPIS) Framework. The International Journal of Health Planning and Management.
