Introduction

Adolescent suicidal behavior remains a global public health concern [1], especially in the uncertain territory of the COVID-19 pandemic and its consequences on mental health [2]. According to global statistics, suicide is the fourth leading cause of death in people aged 15–19, although the rates have decreased since 2008 [3]. Suicide causes 4.06% of healthy life-year losses for this age group [4].

School contexts offer unique opportunities to implement adolescent suicide prevention programs [5], with venues where most interventions for this population are conducted [6]. Generally, school-based programs for adolescent suicide prevention (SBASP) involve one or more components, such as gatekeeper training, suicide awareness education, help-seeking promotion, screening, and social-emotional learning interventions [7]. Evidence for their effectiveness in suicide prevention is inconclusive. Some relevant outcomes are increased suicide awareness and reduced suicide behavior stigma; few studies have demonstrated direct effects on suicide behavior reduction and psychological wellness improvement [8].

However, effectiveness studies appear to be insufficient to assess the outcomes of suicide prevention programs. Recommendations for effective SBASP emphasize considering contextual factors, implementation strategies, and delivery characteristics as critical elements in their design [9]. Evidence suggests that the implementation conditions and settings operate as effectiveness moderators [10]. The World Health Organization (WHO) indicated that suicide prevention program evaluations should also consider implementation indicators in their most recent suicide prevention guidelines [11]. More studies are necessary to understand the heterogeneity of SBASP effectiveness across settings, and what types of interventions work for specific institutional cultures and participants [12]. Research centered on the implementation process of SBAPS can contribute to identifying the optimal strategies for implementing these interventions.

Implementation science studies methods, processes, and core elements associated with successfully integrating evidence-based practices (EBPs) into real-world settings to improve health services and care [13]. Incorporating implementation effectiveness into program evaluations makes assessing interventions’ internal and external validity possible, helping determine whether their failure or success was due to a lack of effectiveness in the new context, how they were delivered, or both. An exemplary implementation makes it possible to maximize the benefits for participants, for example, in prevention programs [14].

Implementation occurs through various strategies defined as methods, techniques, or activities to put into practice and sustain evidence-based innovations; the strategies are the implementation how. To understand the implementation process, the effectiveness of its strategies, and implementation success, it is necessary to measure its outcomes [14–16].

This field has generated solid frameworks to guide research, including the Implementation outcomes framework (IOF) developed by Proctor and colleagues [15]. This heuristic taxonomy organizes implementation outcomes around eight core constructs: acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability. The IOF operationalizes implementation outcomes, emphasizing differences and interrelations between intervention and client outcomes [17]. For its part, the Expert Recommendations for Implementing Change (ERIC) Project developed a taxonomy of implementation strategies, proposing a common language of 73 categories based on the consensus of researchers and implementers of interventions in healthcare [18]. Recently, this taxonomy was adapted in the School Implementation Strategies, Translating ERIC Resources (SISTER) project through a methodology similar to that used in the initial construction, resulting in 75 discrete categories of implementation strategies for school contexts [19].

Methods

A scoping review is the best way to explore the extent of the literature, map and summarize the findings, and inform future research in an emerging field. Scoping reviews incorporate a wide range of evidence and research methodologies through an explicit, rigorous, and replicable method [29, 30]. The proposed scoping review will be conducted following standard methods and the JBI Manual for Evidence Synthesis [29], comprising six stages: 1) definition of objectives and questions, 2) development of inclusion criteria, 3) planning of the search strategy, 4) selection of evidence sources, 5) data extraction process, and 6) data analysis and presentation (Fig 1).

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Fig 1. Scoping review stages.

https://doi.org/10.1371/journal.pone.0284431.g001

The review protocol was registered in the Open Science Framework (https://osf.io/v8gbn/) [31] and is reported in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews (PRISMA-ScR) (S1 Checklist) [30]. Ethical approval is not required for this study.

Inclusion criteria

Participants.

Based on the WHO adolescent criteria, this review will consider studies that include school students between 10 and 19 years [11]. Studies with participants outside this age range will be considered if the mean age of the sample is within the inclusion criterion.

Concept.

To be included in the review, studies should evaluate the implementation of SBASP. The clinical effectiveness or efficacy of these programs must have been proven; alternatively, programs must have been EBPs. To be eligible, studies must report implementation strategies used and/or implementation outcomes, the latter according to the IOF [15]. The studies could use various instruments or data sources from several approaches to evaluate the implementation. Studies focusing only on the efficacy, effectiveness, and clinical outcomes of intervention will be excluded since these studies typically do not incorporate implementation outcomes such as the ones we intend to document. Likewise, we will exclude programs whose main objectives do not include suicide behavior prevention, instead featuring it as a secondary target or an indirect result since this is out of the scope of our review. Table 1 provides a brief definition of the key concepts of the protocol.

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Table 1. Definitions of key concepts scoping review.

https://doi.org/10.1371/journal.pone.0284431.t001

Context.

The interventions must be implemented in the school context. There will be no restrictions on geographical location, provider staff type, delivery modes, length, or sociocultural characteristics (e.g., gender, ethnicity, racialized groups).

Types of sources.

Published and unpublished primary sources of evidence and reviews will be included. In line with the nature of implementation science, a broad range of research designs will be considered for inclusion. Quantitative, qualitative, or mixed-method study designs will be considered, including experimental and quasi-experimental study designs, case reports, and hybrid effectiveness-implementation studies. Additionally, we will consider literature reviews, such as systematic reviews, scoping reviews, and meta-analyses, to identify primary sources. Gray literature will be included to maximize the number of potential studies eligible for inclusion, reduce publication bias, and gain knowledge from interventions implemented by governments, international agencies, or non-governmental organization initiatives (e.g., reports, policy briefs). Textbooks, program evaluations, toolkits, and guidelines will also be considered. This review will exclude documents comprising non-empirical reports, such as protocols, methodological papers, dissertations, newsletters, or opinion papers, since these records do not present original results or may not have been peer-reviewed. Theses and conference proceedings will also be excluded.

Discussion

Before the COVID-19 pandemic, suicide was among the leading causes of adolescent death, surpassed only by traffic accidents, interpersonal violence, and tuberculosis, causing 4.06% of healthy life-years losses and around 35.999 deaths per year for this age group [3, 4, 34].

The impact of COVID-19 on mental health and socioeconomic determinants has a potential intensifier of suicidal risk, especially in young people and high at-risk populations; therefore, efforts to deliver effective suicide prevention strategies should be a priority [35]. SBAPS are recommended preventive intervention that allows easy and continuous access to this population [5, 6]. However, it is necessary to identify the best ways to implement it in real-world contexts, considering the effects of implementation conditions on the intervention effectiveness, such as delivery characteristics or contextual factors [9, 10]. Implementation science applied to suicide prevention is a growing field that optimizes the installation, relevance, and scale-up of EBPs in real-world contexts [22], increasing the external validity, applicability, and usefulness of the findings [36]. Implementation studies offer contextual keys for future designs and evaluation programs and multilevel suicide prevention models; implementation evaluations are particularly valuable for lessons learned, considering that suicide prevention interventions require significant amounts of time and resources for their design, implementation, and sustainability [37]. Applying implementation science to youth mental health interventions is possible to know how and why they work or not, which could allow increasing their impact to face the post-COVID-19 era [38].

We conduct a scoping review to provide the first overview of the scope of implementation research applied to adolescent suicide prevention programs in the school setting to know what implementation strategies and outcomes are reported by these programs and how they are evaluated. In addition, we expect to distinguish the implementation strategies and outcomes employed according to the components and prevention level of evaluated programs. We chose this type of evidence synthesis due to its appropriateness to map and summarize an emerging field [29, 30] as implementation science applied to SBASP.

Once completed, our review will provide a better understanding of the emerging field by examining how the implementation evaluation is conducted, which implementation strategies are most reported in the school context, and the most used implementation results to evaluate their success. In addition, our study may be a precursor to further focused syntheses of evidence that can address more specific research questions. The results may encourage research on more in-depth evaluations of interventions to reduce adolescent suicide in the school setting, including their implementation. The findings may improve the design of new interventions and their translation to different contexts; thus, the review will be disseminated to policymakers, stakeholders, and researchers from health and education.

Limitations

The significant limitations of our review are the need for a formal assessment of study quality and the unstructured character of results synthesis, which is characteristic of a scoping review. The substantial variation we anticipate in study designs and concepts evaluated precludes such formalisms, as we expect to find everything from qualitative studies to randomized controlled trials. However, our review will establish conceptual boundaries and knowledge gaps to inform future synthetic efforts, more direct in scope (e.g., systematic reviews, meta-analysis).

Another shortcoming is the language limiters, which restrict us to English or Spanish literature in which the reviewers are fluent. Still, we assume this criterion will not significantly affect the findings since the journals that publish content relevant to implementation science are mainly in English [39].

Any amendments made during the study will be included in the protocol registry and are reported in the results manuscript.

Supporting information