A just-in-time adaptive intervention (JITAI) for suicide prevention in Nepal - ABSTRACT Suicide is a significant global health issue, contributing to an alarming one million deaths each year. Of particular significance is the heightened risk for suicide observed among homosexual cisgender men (HCM). While innovative suicide prevention strategies, particularly app-based interventions, have been developed, there is limited data on their applicability and real-world implementation in low-resource or rural contexts. Nepal offers an ideal setting to fill this gap, given that nearly all men use smartphones and mental health services are limited. Lessons from Nepal will inform the development of scalable, culturally competent, and adaptable suicide prevention strategies in the United States. Moreover, intervention delivery is not temporally optimized to address the dynamic nature of suicide risk, suggesting the need for an adaptive approach to intervention delivery. Just-in-time adaptive interventions (JITAIs) represent an innovative approach by deploying a tailored intervention when needed. Specifically, apps that incorporate JITAI can be more effective than traditional app-based interventions by addressing the dynamic nature of suicidal thoughts and behaviors (STBs). Although JITAI has been utilized effectively to address addiction, physical inactivity, and obesity, it has not yet been applied to suicide prevention for ho. To address this gap, we propose developing and testing Chissa – an app-based JITAI designed to identify suicide risk and deliver tailored interventions for HCM in Nepal. The proposed research builds on our prior work and a long history of collaboration with local partners in Nepal. Specifically, we will utilize the Discover, Design, Build, and Test (DDBT) model, which incorporates principles of human-centered design, to adapt, refine, and extend features of the existing apps, which will be integrated into the existing clinics providing healthcare services to HCM communities. We have completed the first phase of the DDBT model (Discover), which involved conducting focus groups with HCM and other stakeholders to explore the parameters of the Chissa JITAI. To develop an empirically-informed Chissa JITAI, we will first, conduct at least three co-design sessions with a team of HCM and other stakeholders (N=10) to build consensus around JITAI features/content and develop implementation strategies based on the outputs from the Discover Phase, followed by the development of the Chissa app (Design and Build Phase; Aim 1). Second, we will conduct a 30-day micro-randomized trial (N=30) of the Chissa app to assess its usability and the impact of its JITAI components on STBs to optimize it (Test Phase; Aim 2). Next, we will conduct a type 1 hybrid implementation science trial that involves an assessment of the efficacy of the Chissa app (Aim 3a) while assessing contextual implementation factors to guide its future adoption and scale-up (Aim 3b). If efficacious, the Chissa app, capable of identifying users’ suicidal risk and delivering tailored intervention, could help shape culturally responsive and scalable interventions to help reduce the suicide burden in the United States.
