Suicide prevention program (SPP) in South Asian Countries: A protocol for systematic review

Kallabi Borah; Tessy Treesa Jose; Anil Kumar Mysore Nagaraj; Lorna Moxham

doi:10.12688/f1000research.132215.1

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Study Protocol

Suicide prevention program (SPP) in South Asian Countries: A protocol for systematic review

[version 1; peer review: 1 approved, 1 approved with reservations]

Kallabi Borah¹, Tessy Treesa Jose ², Anil Kumar Mysore Nagaraj³, Lorna Moxham⁴

PUBLISHED 20 Apr 2023

Author details Author details

¹ Psychiatric Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Udupi, Karnataka, 576104, India
² Psychiatric Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Udupi, Karnataka, 576104, India
³ Psychiatry, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Udupi, Karnataka, 576104, India
⁴ Mental Health Nursing, University of Wollongong, Wollongong, New South Wales, Australia

Kallabi Borah
Roles: Conceptualization, Formal Analysis, Methodology, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Tessy Treesa Jose
Roles: Conceptualization, Formal Analysis, Methodology, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Anil Kumar Mysore Nagaraj
Roles: Conceptualization, Formal Analysis, Methodology, Supervision, Validation, Visualization, Writing – Review & Editing

Lorna Moxham
Roles: Conceptualization, Methodology, Supervision, Validation, Visualization, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Manipal Academy of Higher Education gateway.

Abstract

Introduction: Every year, over 703,000 individuals lose their life by suicide and many individuals attempt suicide. Suicide occurs in all age groups and is the fourth major cause of death among 15–29-year-olds globally in 2019. A suicide prevention program (SPP) is a capacity-building program that helps gatekeepers to identify the risk of suicide. The objective of the review is to determine the effectiveness of SPP on the improvement of knowledge, attitude, and gatekeeper behaviour among gatekeepers in South Asian countries.
Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and PICO (Population, Intervention, Comparison, Outcome) format will be followed in this review. This review will include all interventional studies that provided a suicide prevention program to the gatekeepers as an intervention. The full-text articles will be included from the following databases, Scopus, PubMed (MEDLINE), Cochrane, PsycINFO, Web of Science, and CINAHL, published in peer-reviewed, indexed, and English language journals from the date of inception to 2022. A grey literature search and hand-search of reference lists of the included studies will also be done. A search strategy will be developed using keywords and MeSH terms for each database. Cochrane ROB-2 tool, JBI Critical Appraisal Checklist, Critical Appraisal Skills Program (CASP), and Mixed Methods Appraisal Tool (MMAT) will be used to evaluate the quality of individual studies. Analysis of the data will be done using narrative synthesis.
Conclusions: This review will provide information on knowledge, attitude, and gatekeeper behaviour toward suicide prevention in college students and will be helpful for the prevention of suicide. Therefore, the authors plan to publish the review outcome through a peer-reviewed journal.
Registration: The review is registered in PROSPERO (CRD42023387020).

Keywords

systematic review, South Asian countries, college students, suicide prevention, suicide prevention program.

Corresponding author: Tessy Treesa Jose

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2023 Borah K et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Borah K, Jose TT, Mysore Nagaraj AK and Moxham L. Suicide prevention program (SPP) in South Asian Countries: A protocol for systematic review [version 1; peer review: 1 approved, 1 approved with reservations]. F1000Research 2023, 12:425 (https://doi.org/10.12688/f1000research.132215.1) First published: 20 Apr 2023, 12:425 (https://doi.org/10.12688/f1000research.132215.1) Latest published: 30 May 2023, 12:425 (https://doi.org/10.12688/f1000research.132215.2)

Introduction

Suicide is an emergency problem in psychiatry. It is one of the major causes of death among today’s youth.¹ Several factors such as biological, psychological, and environmental factors are associated with youth suicide, varying from family issues to rapid urbanization and a weak psychological system.² Childhood abuse (physical, emotional, and sexual) also plays a role in future suicidal ideation among youth.³^,⁴

The suicide rate is increasing every year. The World Health Organization (WHO) reported that one individual dies by suicide every 40 seconds. Worldwide, every year more than 700,000 individuals take their life by suicide, and many individuals attempt suicide.⁵ The UN’s Sustainable Development Goal (SDG) 3 is “Ensure healthy lives and promote well-being for all at all ages” and the target SDG 3.4 explains “By 2030, reduce by one-third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being” under which one indicator (SDG3.4.2) is the suicide mortality rate.⁶ A total of 79% of the world’s suicide occurred in low and middle-income countries.⁷ Worldwide, a total of 1.4% of all deaths are associated with suicide among those aged 15-24 years (Web-based Injury Statistics Query and Report System [WISQARS], 2017) and it is the fourth major cause of death among those aged 15 to 29.⁸ The calculated age-standardized suicide rate among those aged 15 years or more was 22.0 per 100,000.⁹

India has the highest suicide rate in the Southeast Asia region.¹⁰ According to a WHO report (Sep 9, 2019), the rate of suicide in India is 16.5 per 100,000 people.¹¹ In India (2021) out of 13,089 students who died by suicide, 7,396 were male and 5,693 were female.¹² A review reported that compared to other high-income countries, Asia has higher average suicide rates.¹³ Very few reviews are available on suicide in South Asia, and only India and Sri Lanka have been included in most of the reviews.¹⁴

The National Crime Records Bureau (2017) reported that one student commits suicide every hour, and one of the major causes of suicide is a failure in examinations.¹⁵^,¹⁶ The other causes that lead to suicide among students are depression, relationship issues, psychiatric problems requiring medical attention, a history of psychiatric hospitalization, and academic obstacles.¹⁷

A gatekeeper can be anyone (e.g., teachers, parents, hostel wardens, community leaders, police, layperson, counsellors, among others) who is ready to give time and effort to prevent suicide at the community level.¹⁸ A gatekeeper training program is a capacity-building suicide prevention program recommended by WHO that aims to assist individuals with the skills and knowledge required to be first responders to someone who is in psychological distress and potentially suicidal and helps them to get better services as needed. As suicide is a growing problem among adolescents, suicide prevention program will help the gatekeepers identify the risk of suicide at the grass root level. Therefore, this review is intended to determine the effect of suicide prevention programs among gatekeepers on the prevention of suicide among college students in South Asia (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka)¹⁹ and to improve their knowledge, attitude, and gatekeeper behaviour through suicide prevention program.

Objective

The objective of the review is to determine the effectiveness of suicide prevention programs (SPP) on the improvement of knowledge, attitude, and gatekeeper behaviour among gatekeepers so that the number of suicide cases will be reduced among college students in South Asia countries.

Review question

• Are suicide prevention programs effective among gatekeepers in the prevention of suicide among college students?
• What types of suicide prevention programs are effective in the prevention of suicide among college students?
• What are the components that make suicide prevention programs effective?
• Does the suicide prevention program help in the improvement of knowledge, attitude, and gatekeeper behaviour among gatekeepers?

Methods

Eligibility criteria

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)²⁰ will be used to report systematic reviews. The PICO (Population, Intervention, Comparison, Outcome) format will be adopted to define the methods of the review. The protocol was registered on PROSPERO (CRD42023387020).

Types of studies

All interventional studies that provide suicide prevention programs to the gatekeepers as an intervention to prevent suicide in college students, and published in indexed and peer-reviewed, English language journals from the date of inception to 2022 in South Asia will be included. A grey literature search and hand-search of reference lists of included studies will be done. The conference proceedings, reports, review papers, letters to the editor, or responses to articles, as well as studies published in other than English will not be included.

Participants

Gatekeepers who have undergone any suicide prevention program as an intervention will be the participants in the present review.

Intervention

We will include studies that provide suicide prevention programs as an intervention in the form of a workshop, different methods of teaching, and a module/booklet.

Comparison

We will include studies that compare the intervention group (receiving any intervention in suicide prevention) and the control group (not receiving any intervention in suicide prevention).

Outcome measures

The outcome measures will be suicide prevention, knowledge, attitude, and gatekeeper behaviour.

Information sources

Primary studies will be searched by two independent authors through electronic databases: Scopus, PubMed (MEDLINE), PsycINFO, Cochrane, Web of Science, and CINAHL using MeSH terms, Emtree and synonyms of keywords of a suicide prevention program, South Asia, gatekeepers, and college students. Boolean operators (AND, OR) will be used to create specific search strategies for each database.

Additional searches

a) Hand searching: To find out additional studies, authors will hand-search reference lists of all primary studies and review articles.
b) Grey literature: Authors will conduct a grey literature search to find out the studies not indexed in the above-listed databases.

Search strategy

We include the search strategy in Figshare (Extended data).²¹

Study records

Data management

RevMan 5 software²² will be used for the screening and data extraction of the review. The collected search results from the databases will be kept in one folder and will be imported into EndNote and will be arranged by databases, inclusion criteria, and exclusion criteria.

Selection process

A stepwise approach will be followed by the authors to identify the eligibility of the studies for inclusion in this review. To identify eligibility and remove duplicates, titles and abstracts of the studies will be screened by two authors independently. The full-text article screening will be done for the potentially eligible studies. The full-text studies will be retrieved and assessed for inclusion in the review by two reviewers. A third reviewer or an independent opinion may be requested if the first two reviewers are unsure about the study’s eligibility in the analysis. The results from independent reviewers will be sent to a third reviewer, who will compare the results and compile a list of included studies. Discrepancies between the results from both reviewers will be discussed with the third reviewer until an agreement is reached. If the full-text study is not accessible through institutional membership, then the study authors will be contacted to retrieve the manuscript. The study will be included based on inclusion criteria. After eliminating the duplicate studies, a final list of included studies will be made. The reason for the excluded study and the study selection procedure will be recorded in the PRISMA flow diagram.

Data collection process

Following the study selection process, the extraction of the data will be completed independently by two authors. To ensure consistency in the data extraction, the authors will first pilot the data extraction tool and the extraction process on the first ten articles. Outcome data and characteristics of the study will be included if reported within the individual studies (study authors will be contacted to collect missing information relevant to this review). A data extraction form will be used to extract the data by two independent authors.

Data items

Bibliometric information such as authors’ names, titles, journal names, publication year, and settings will be collected along with included study characteristics such as type of study, research question, objective, observation, duration, intervention, outcome variables, and key findings.

Outcome and prioritization

The evidence generated through this review will be presented in the form of tables and figures and based on the study objectives narrative synthesis will be done.

Risk of bias in individual studies

The Cochrane ROB-2 tool will be used to assess the risk of bias in individual studies.²³ Quality assessment will be performed by two authors to conclude inconsistency by consulting with a third author.

Quantitative studies

The Joanna Briggs Institute (JBI) Critical Appraisal Checklist will be used to assess the risk of bias and selection bias.

Qualitative studies

The Critical Appraisal Skills Program (CASP) checklist will be used to assess the quality of the studies.²⁴

Mixed methods studies

The risk of bias for mixed-method studies will be assessed by the Mixed Methods Appraisal Tool (MMAT).²⁵ The assessment will be done based on the following domains of bias: (i) randomization process, (ii) deviation from intervention (allocation concealment sequence), (iii) outcome assessment, (iv) incomplete outcome data, (v) selective reporting, and (vi) absolute bias. Based on the risk of bias assessment, the studies will be classified as high, or low risk of bias.

Data synthesis

Collected data will be described and synthesized according to the type of sources, context, and key themes. The authors will perform a meta-analysis where feasible. As part of the preliminary analysis, the sensitivity and specificity of the included studies will be shown by forest plots and receiver operating characteristics curve. A summary table will be used to depict the most important aspects of the selected studies, such as the research area, and how the suicide prevention program is effective in suicide prevention. Factors gleaned from quantitative investigations will be presented in a narrative study. Thematic analysis will be done to study the qualitative data to track down the variables. The data will be coded, and subthemes will be developed after that.

Sensitivity analysis

To determine the low impact of quality studies on the review findings sensitivity analyses will be performed. A high or unclear risk of bias studies as identified by the ROB-2 tool will be excluded.

Reporting bias assessment

Reporting bias will not be assessed due to a lack of sensitive statistical methods.

Confidence in cumulative evidence

The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidance²⁶ will be used by two reviewers independently to assess the quality of evidence and it will be classified as high, moderate, low, or very low.

Discussion

The gatekeeper training helps the gatekeepers to improve their knowledge and lower their judgmental attitude towards suicide prevention.²⁷ Previous studies also revealed that gatekeeper training (GKT) improves the teachers’ competency and confidence in managing suicide-risk students.²⁸^,²⁹ The study also reported that GKT brushed up the self-perceptions of college staff in working with suicidal students and improve their skill for providing intervention.³⁰

Ethics and dissemination

Ethical clearance is not applicable as the present review will include only published articles from different databases and no human will participate in this review. A manuscript will be prepared for publication in a Scopus-indexed, peer-reviewed journal and the results will be presented at a national and international conference after the completion of the analysis.

Strengths and limitations

The present systematic review will include interventional studies which provide suicide prevention program to the gatekeepers as an intervention. This review will focus on suicide prevention among college students. Only studies published in the English language in South Asian countries will be included.

Study status

Formal search has not been started.

Author contributions

Kallabi Borah: Conceptualization, analysis, methodology, supervision, validation, writing- original draft preparation, writing- review & editing.

Tessy Treesa Jose: Conceptualization, analysis, methodology, supervision, validation, visualization, writing- review & editing.

Anil Kumar Mysore Nagaraj: Conceptualization, analysis, methodology, supervision, validation, visualization, writing- review & editing.

Lorna Moxham: Conceptualization, methodology, supervision validation, visualization, writing- review & editing.

Data availability

Underlying data

No data are associated with this article.

Extended data

Figshare: Supplementary material 1, https://doi.org/10.6084/m9.figshare.22249906.³¹

This project contains the following extended data:

- PRISMA flow diagram of study selection for, “Suicide prevention program (SPP) in South Asian Countries: A protocol for systematic review”

Figshare: Supplementary material 3, https://doi.org/10.6084/m9.figshare.22253254.²¹

This project contains the following extended data:

- Search strategy for “Suicide prevention program (SPP) in South Asian Countries: A protocol for the systematic review”

Reporting guidelines

Figshare: PRISMA-P checklist for, “Suicide prevention program (SPP) in South Asian Countries: A protocol for systematic review, https://doi.org/10.6084/m9.figshare.22252309.³²

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0)

References

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2. Sreevani R: A Guide to mental health and psychiatric nursing. 4th ed.New Delhi: JAYPEE; 2016; 253–254.
3. Arun P, Garg R, Chavan BS: Stress and suicidal ideation among adolescents having academic difficulty. Ind. Psychiatry J. 2017; 26: 64–70. PubMed Abstract | Publisher Full Text | Free Full Text
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17. Cimini MD, Rivero EM, Bernier JE, et al.: Implementing an audience-specific small-group gatekeeper training program to respond to suicide risk among college students: A case study. J. Am. Coll. Heal. 2014; 62(2): 92–100. PubMed Abstract | Publisher Full Text
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Comments on this article Comments (0)

Version 2

VERSION 2 PUBLISHED 20 Apr 2023

Author details Author details

Kallabi Borah
Roles: Conceptualization, Formal Analysis, Methodology, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Tessy Treesa Jose
Roles: Conceptualization, Formal Analysis, Methodology, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Anil Kumar Mysore Nagaraj
Roles: Conceptualization, Formal Analysis, Methodology, Supervision, Validation, Visualization, Writing – Review & Editing

Lorna Moxham
Roles: Conceptualization, Methodology, Supervision, Validation, Visualization, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (2)

version 2

Revised

Published: 30 May 2023, 12:425

https://doi.org/10.12688/f1000research.132215.2

version 1

Published: 20 Apr 2023, 12:425

https://doi.org/10.12688/f1000research.132215.1

© 2023 Borah K et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Borah K, Jose TT, Mysore Nagaraj AK and Moxham L. Suicide prevention program (SPP) in South Asian Countries: A protocol for systematic review [version 1; peer review: 1 approved, 1 approved with reservations]. F1000Research 2023, 12:425 (https://doi.org/10.12688/f1000research.132215.1)

NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.

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Open Peer Review

Version 1

VERSION 1

PUBLISHED 20 Apr 2023

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Reviewer Report 10 May 2023

Stuart Leske, UQ Poche Centre for Indigenous Health, The University of Queensland, Toowong, Queensland, Australia

Approved with Reservations

https://doi.org/10.5256/f1000research.145123.r170503

Thank you for the opportunity to review this systematic review protocol. The review plans to examine the effectiveness of gatekeeper training for suicide prevention in college students in South Asian countries.

Abstract, introduction: If the 703,000 figure is taken from WHO’s suicide estimates worldwide in 2019, it’s just 703,000 (not more), or you could say ‘over 700,000’.

Abstract, introduction: What would be the reason for calling the intervention a suicide prevention program (SPP), rather than using the term ‘gatekeeper training’? Note that all of the previous reviews in this field use the latter term:

Yonemoto, N., Kawashima, Y., Endo, K., & Yamada, M. (2019). Implementation of gatekeeper training programs for suicide prevention in Japan: a systematic review. International journal of mental health systems, 13, 1-6.
Morton, M., Wang, S., Tse, K., Chung, C., Bergmans, Y., Ceniti, A., ... & Rizvi, S. (2021). Gatekeeper training for friends and family of individuals at risk of suicide: a systematic review. Journal of community psychology, 49(6), 1838-1871.
Torok, M., Calear, A. L., Smart, A., Nicolopoulos, A., & Wong, Q. (2019). Preventing adolescent suicide: A systematic review of the effectiveness and change mechanisms of suicide prevention gatekeeping training programs for teachers and parents. Journal of adolescence, 73, 100-112.
Nasir, B. F., Hides, L., Kisely, S., Ranmuthugala, G., Nicholson, G. C., Black, E., ... & Toombs, M. (2016). The need for a culturally-tailored gatekeeper training intervention program in preventing suicide among Indigenous peoples: a systematic review. BMC psychiatry, 16, 1-7.
Mo, P. K., Ko, T. T., & Xin, M. Q. (2018). School-based gatekeeper training programmes in enhancing gatekeepers’ cognitions and behaviours for adolescent suicide prevention: a systematic review. Child and adolescent psychiatry and mental health, 12, 1-24.
Burnette, C., Ramchand, R., & Ayer, L. (2015). Gatekeeper training for suicide prevention: A theoretical model and review of the empirical literature. Rand health quarterly, 5(1).
Isaac, M., Elias, B., Katz, L. Y., Belik, S. L., Deane, F. P., Enns, M. W., ... & Swampy Cree Suicide Prevention Team (12 members) 8. (2009). Gatekeeper training as a preventative intervention for suicide: a systematic review. The Canadian Journal of Psychiatry, 54(4), 260-268.
Holmes, G., Clacy, A., Hermens, D. F., & Lagopoulos, J. (2021). The long-term efficacy of suicide prevention gatekeeper training: a systematic review. Archives of suicide research, 25(2), 177-207.
Yonemoto, N., Kawashima, Y., Endo, K., & Yamada, M. (2019). Gatekeeper training for suicidal behaviors: A systematic review. Journal of affective disorders, 246, 506-514.

Perhaps you could say ‘gatekeeper training for suicide prevention’?

Abstract, methods: I think you don’t need to mention PICO here, as it is within PRISMA-P.

Abstract, methods: When mentioning ‘interventional studies’, you may need to specify study designs. Would these be any intervention study design, controlled or uncontrolled?

Abstract, methods: If looking purely at effectiveness, the authors may not need all these study quality assessment tools. For example, the MMAT may not be needed if the authors don’t plan to synthesise qualitative data.

Introduction, first paragraph: You could probably say that suicide is a global public health issue, as it’s typically considered to be, rather than just a problem for psychiatry.

Introduction, first paragraph: Who does ‘today’s youth’ refer to? Is this in India or globally? Perhaps state where it ranks in the leading causes of death among these youth. The two sentences on youth may also need to be about all ages if this review does not look at gatekeeper interventions for youth specifically.

Introduction, first paragraph: I’m not sure what is meant by a ‘weak psychological system’, but you need to revise the language here to make this term more technical.

Introduction, second paragraph: The statement ‘The suicide rate is increasing every year’ is incorrect. WHO’s Global Health Estimates reported that ‘In the 20 years between 2000 and 2019, the global age-standardized suicide rate decreased by 36%’ -https://www.who.int/publications/i/item/9789240026643

Introduction, second paragraph: ‘The statement that 79% of the world’s suicide occurred in low and middle-income countries.’ Is a secondary citation in the document you cite. The primary citation is WHO data from 2016, and is actually 77% rather than 79%. I recommend instead citing https://www.who.int/publications/i/item/9789240026643. The updated figure for 2019 is 77%, the same as the 2016 figure but with a better citation.

Introduction, second paragraph: WISQARS would need to be referenced in the reference list. I understand that WISQARS is US only. You could instead cite the WHO global health estimates again, and paraphrase a statement like: ‘Suicide was the fourth leading cause of death in young people aged 15–29 years for both sexes’ https://www.who.int/publications/i/item/9789240026643. Reference 8 is a 2014 document, but is superseded now by these estimates.

Introduction, third paragraph: I think the first sentence of this just needs updating with the WHO report again. https://www.who.int/publications/i/item/9789240026643 It now looks like Sri Lanka has a higher rate for both sexes.

Introduction, third paragraph: I think reference 13 is outdated now, and the WHO global estimates for 2019 should be used instead. With regards to reference 14, I think you should look at the most recent review of gatekeeper training to see if studies from South Asia were included, as that is most relevant to your review and justifies why this new review is necessary.

Introduction, fourth paragraph: Best to avoid the word ‘commits’, and say ‘dies by suicide’ instead.

Introduction, fifth paragraph: It isn’t clear in the abstract that the review will be about college students only. Could you check that it is consistent? You also just need to cite citation 6 in the Wikipedia page, which is the Encyclopedia of Modern Asia.

Methods, types of studies: Is it possible that the authors can include studies in languages they speak, which might include some languages other than English? This would be a major strength of the review if you could do this and found studies in your languages.

Methods, outcome measures: I think you need to describe the outcome measures more specifically. How would you measure suicide prevention and gatekeeper behaviour? And you may just need to specify what ‘knowledge’ and ‘attitude’ refer to…

Methods, hand searching – do you mean included studies, when you say primary studies? It might be better to say ‘included’ studies, as primary studies mean every bit of original research you find.

Study records, data management: You just need to cite EndNote: https://support.clarivate.com/Endnote/s/article/Citing-the-EndNote-program-as-a-reference?language=en_US

Data synthesis - What do you mean by the sensitivity and specificity of the included studies? Their ability to rule in and rule out what condition? What do you mean by ‘to track down the variables?’

Discussion – I’m not sure the first paragraph is necessary as it’d be good to talk about your review here.

Extended data – you don’t need to include the PRISMA flow diagram at this stage.

Extended data – with the search terms, you just need to clarify if this is for PubMed?

I think you might need to make the case for why this review is necessary, as I’m not sure it will find a lot of studies. You could say that previous reviews last searched the literature in February 2017 (Yonemato et al., 2019) and May 2018 (Torok et al., 2019), and you know that studies have been published since. Or maybe these reviews were limited to developed settings, although I don’t think this would be the case.

Just related to PRISMA-P, I couldn’t see:

Who the guarantor is for the review
A statement on funding
The section on outcomes and prioritization needs to discuss if any outcomes are primary and if any are secondary, and just describe the outcomes in more detail. I would see the PRISMA-P explanation and elaboration statement for an understanding of what you need to say here: http://www.bmj.com/content/349/bmj.g7647
You would need to talk about whether you wanted to assess meta-biases with for example, a funnel plot for publication bias. I’d encourage seeing the E and E statement on this item again: http://www.bmj.com/content/349/bmj.g7647

Is the rationale for, and objectives of, the study clearly described?

Partly
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Partly
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Suicide prevention research and systematic reviews.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

CITE

Report a concern

Author Response 29 Nov 2023

Tessy Treesa Jose, Psychiatric Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Udupi, 576104, India

29 Nov 2023

Author Response
Thank you for peer-reviewing our article.

Abstract, introduction: If the 703,000 figure is taken from WHO’s suicide estimates worldwide in 2019, it’s just 703,000 (not more), or you could ... Continue reading
Thank you for peer-reviewing our article.

Abstract, introduction: If the 703,000 figure is taken from WHO’s suicide estimates worldwide in 2019, it’s just 703,000 (not more), or you could say ‘over 700,000’.
The authors are thankful for your kind suggestion. As per the suggestions, modifications are carried out in the revised manuscript.

Abstract, introduction: What would be the reason for calling the intervention a suicide prevention program (SPP), rather than using the term ‘gatekeeper training’?
In the present systematic review, suicide prevention program (SPP) refers to any teaching intervention/program in the form of a workshop/ different methods of teaching/ module/booklet to gatekeepers on suicide prevention in college students. Therefore, the authors used the term “suicide prevention program”.

Abstract, methods: I think you don’t need to mention PICO here, as it is within PRISMA-P.
The authors completely agree with the reviewer on this point.

Abstract, methods: When mentioning ‘interventional studies’, you may need to specify study designs. Would these be any intervention study design, controlled or uncontrolled?
We thank the reviewer for this comment. In this review, the authors will include any interventional study designs (controlled and uncontrolled).

Abstract, methods: If looking purely at effectiveness, the authors may not need all these study quality assessment tools. For example, the MMAT may not be needed if the authors don’t plan to synthesise qualitative data.
Modification is done accordingly.

Introduction, first paragraph: You could probably say that suicide is a global public health issue, as it’s typically considered to be, rather than just a problem for psychiatry.
We would like to thank the reviewer for your kind suggestion. Modifications are made in the revised manuscript.

Introduction, first paragraph: Who does ‘today’s youth’ refer to? Is this in India or globally? Perhaps state where it ranks in the leading causes of death among these youth. The two sentences on youth may also need to be about all ages if this review does not look at gatekeeper interventions for youth specifically.
We thank the reviewer for this comment. This sentence is restructured.

Introduction, first paragraph: I’m not sure what is meant by a ‘weak psychological system’, but you need to revise the language here to make this term more technical.
We thank the reviewer for this comment. Modifications are made accordingly.

Introduction, second paragraph: The statement ‘The suicide rate is increasing every year’ is incorrect. WHO’s Global Health Estimates reported that ‘In the 20 years between 2000 and 2019, the global age-standardized suicide rate decreased by 36%’ -https://www.who.int/publications/i/item/9789240026643
We thank the reviewer for this comment. This sentence is removed from the revised manuscript.

Introduction, second paragraph: ‘The statement that 79% of the world’s suicide occurred in low and middle-income countries.’ Is a secondary citation in the document you cite. The primary citation is WHO data from 2016, and is actually 77% rather than 79%. I recommend instead citing https://www.who.int/publications/i/item/9789240026643. The updated figure for 2019 is 77%, the same as the 2016 figure but with a better citation.
We would like to thank the reviewer for your kind suggestion. Modifications are made accordingly.

Introduction, second paragraph: WISQARS would need to be referenced in the reference list. I understand that WISQARS is US only. You could instead cite the WHO global health estimates again, and paraphrase a statement like: ‘Suicide was the fourth leading cause of death in young people aged 15–29 years for both sexes’ https://www.who.int/publications/i/item/9789240026643. Reference 8 is a 2014 document, but is superseded now by these estimates.
We thank the reviewer for the valuable suggestion. Modifications are made accordingly.

Introduction, third paragraph: I think the first sentence of this just needs updating with the WHO report again. https://www.who.int/publications/i/item/9789240026643 It now looks like Sri Lanka has a higher rate for both sexes.
We thank the reviewer for the suggestion. India and Sri Lanka (12.9%) have the highest suicide rate in the Southeast Asia region.

Introduction, third paragraph: I think reference 13 is outdated now, and the WHO global estimates for 2019 should be used instead. With regards to reference 14, I think you should look at the most recent review of gatekeeper training to see if studies from South Asia were included, as that is most relevant to your review and justifies why this new review is necessary.
We thank the reviewer for the suggestion. Unfortunately, the authors could not find out the most recent reviews of gatekeeper training in South Asian Countries.
Reference 13 deals with the comparison of suicide rates between high-income countries and Asia whereas “Suicide Worldwide in 2019: Global Health Estimates” specifies a comparison between Africa, Europe, and Southeast Asia.

Introduction, fourth paragraph: Best to avoid the word ‘commits’ and say ‘dies by suicide’ instead.
Thank you for notifying me of this point. The text is modified as per the reviewer’s suggestion in the revised manuscript.

Introduction, fifth paragraph: It isn’t clear in the abstract that the review will be about college students only. Could you check that it is consistent? You also just need to cite citation 6 in the Wikipedia page, which is the Encyclopedia of Modern Asia.
We thank the reviewer for the constructive suggestion. Modifications are made accordingly. We have not taken citation 6 from the Wikipedia page.

Methods, types of studies: Is it possible that the authors can include studies in languages they speak, which might include some languages other than English? This would be a major strength of the review if you could do this and found studies in your languages.
The authors completely agree with the reviewer on this point.

Methods, outcome measures: I think you need to describe the outcome measures more specifically. How would you measure suicide prevention and gatekeeper behaviour? And you may just need to specify what ‘knowledge’ and ‘attitude’ refer to…
Modifications are made accordingly.

Methods, hand searching – do you mean included studies, when you say primary studies? It might be better to say ‘included’ studies, as primary studies mean every bit of original research you find.
Modifications are made accordingly.

Study records, data management: You just need to cite EndNote: https://support.clarivate.com/Endnote/s/article/Citing-the-EndNote-program-as-a-reference?language=en_US
Modifications are made accordingly.

Data synthesis - What do you mean by the sensitivity and specificity of the included studies? Their ability to rule in and rule out what condition? What do you mean by ‘to track down the variables?’
Thank you for notifying me of this point. This paragraph is restructured.

Discussion – I’m not sure the first paragraph is necessary as it’d be good to talk about your review here.
We thank the reviewer for the kind suggestion. Modifications are made accordingly.

Extended data – you don’t need to include the PRISMA flow diagram at this stage.
The authors completely agree with the reviewer on this point.

Extended data – with the search terms, you just need to clarify if this is for PubMed?
Search terms are for all databases.

I think you might need to make the case for why this review is necessary, as I’m not sure it will find a lot of studies. You could say that previous reviews last searched the literature in February 2017 (Yonemato et al., 2019) and May 2018 (Torok et al., 2019), and you know that studies have been published since. Or maybe these reviews were limited to developed settings, although I don’t think this would be the case.
As per the authors’ knowledge, few reviews have been done to estimate the prevalence of suicide, and factors associated with suicide among students in South Asia. But this review will be done to determine the effectiveness of suicide prevention program (SPP) on the improvement of knowledge, attitude, and gatekeeper behaviour among gatekeepers in South Asian countries so that the number of suicide cases will be reduced among college students in South Asia countries.

Just related to PRISMA-P, I couldn’t see:

Who the guarantor is for the review : Corresponding author.

A statement on funding : Modification is made accordingly.

The section on outcomes and prioritization needs to discuss if any outcomes are primary and if any are secondary, and just describe the outcomes in more detail. I would see the PRISMA-P explanation and elaboration statement for an understanding of what you need to say here: http://www.bmj.com/content/349/bmj.g7647 : Modification is made accordingly.

You would need to talk about whether you wanted to assess meta-biases with, for example, a funnel plot for publication bias. I’d encourage seeing the E and E-statement on this item again: http://www.bmj.com/content/349/bmj.g7647 : Modification is made accordingly.
Thank you for peer-reviewing our article.

Abstract, introduction: If the 703,000 figure is taken from WHO’s suicide estimates worldwide in 2019, it’s just 703,000 (not more), or you could say ‘over 700,000’.
The authors are thankful for your kind suggestion. As per the suggestions, modifications are carried out in the revised manuscript.

Abstract, introduction: What would be the reason for calling the intervention a suicide prevention program (SPP), rather than using the term ‘gatekeeper training’?
In the present systematic review, suicide prevention program (SPP) refers to any teaching intervention/program in the form of a workshop/ different methods of teaching/ module/booklet to gatekeepers on suicide prevention in college students. Therefore, the authors used the term “suicide prevention program”.

Abstract, methods: I think you don’t need to mention PICO here, as it is within PRISMA-P.
The authors completely agree with the reviewer on this point.

Abstract, methods: When mentioning ‘interventional studies’, you may need to specify study designs. Would these be any intervention study design, controlled or uncontrolled?
We thank the reviewer for this comment. In this review, the authors will include any interventional study designs (controlled and uncontrolled).

Abstract, methods: If looking purely at effectiveness, the authors may not need all these study quality assessment tools. For example, the MMAT may not be needed if the authors don’t plan to synthesise qualitative data.
Modification is done accordingly.

Introduction, first paragraph: You could probably say that suicide is a global public health issue, as it’s typically considered to be, rather than just a problem for psychiatry.
We would like to thank the reviewer for your kind suggestion. Modifications are made in the revised manuscript.

Introduction, first paragraph: Who does ‘today’s youth’ refer to? Is this in India or globally? Perhaps state where it ranks in the leading causes of death among these youth. The two sentences on youth may also need to be about all ages if this review does not look at gatekeeper interventions for youth specifically.
We thank the reviewer for this comment. This sentence is restructured.

Introduction, first paragraph: I’m not sure what is meant by a ‘weak psychological system’, but you need to revise the language here to make this term more technical.
We thank the reviewer for this comment. Modifications are made accordingly.

Introduction, second paragraph: The statement ‘The suicide rate is increasing every year’ is incorrect. WHO’s Global Health Estimates reported that ‘In the 20 years between 2000 and 2019, the global age-standardized suicide rate decreased by 36%’ -https://www.who.int/publications/i/item/9789240026643
We thank the reviewer for this comment. This sentence is removed from the revised manuscript.

Introduction, second paragraph: ‘The statement that 79% of the world’s suicide occurred in low and middle-income countries.’ Is a secondary citation in the document you cite. The primary citation is WHO data from 2016, and is actually 77% rather than 79%. I recommend instead citing https://www.who.int/publications/i/item/9789240026643. The updated figure for 2019 is 77%, the same as the 2016 figure but with a better citation.
We would like to thank the reviewer for your kind suggestion. Modifications are made accordingly.

Introduction, second paragraph: WISQARS would need to be referenced in the reference list. I understand that WISQARS is US only. You could instead cite the WHO global health estimates again, and paraphrase a statement like: ‘Suicide was the fourth leading cause of death in young people aged 15–29 years for both sexes’ https://www.who.int/publications/i/item/9789240026643. Reference 8 is a 2014 document, but is superseded now by these estimates.
We thank the reviewer for the valuable suggestion. Modifications are made accordingly.

Introduction, third paragraph: I think the first sentence of this just needs updating with the WHO report again. https://www.who.int/publications/i/item/9789240026643 It now looks like Sri Lanka has a higher rate for both sexes.
We thank the reviewer for the suggestion. India and Sri Lanka (12.9%) have the highest suicide rate in the Southeast Asia region.

Introduction, third paragraph: I think reference 13 is outdated now, and the WHO global estimates for 2019 should be used instead. With regards to reference 14, I think you should look at the most recent review of gatekeeper training to see if studies from South Asia were included, as that is most relevant to your review and justifies why this new review is necessary.
We thank the reviewer for the suggestion. Unfortunately, the authors could not find out the most recent reviews of gatekeeper training in South Asian Countries.
Reference 13 deals with the comparison of suicide rates between high-income countries and Asia whereas “Suicide Worldwide in 2019: Global Health Estimates” specifies a comparison between Africa, Europe, and Southeast Asia.

Introduction, fourth paragraph: Best to avoid the word ‘commits’ and say ‘dies by suicide’ instead.
Thank you for notifying me of this point. The text is modified as per the reviewer’s suggestion in the revised manuscript.

Introduction, fifth paragraph: It isn’t clear in the abstract that the review will be about college students only. Could you check that it is consistent? You also just need to cite citation 6 in the Wikipedia page, which is the Encyclopedia of Modern Asia.
We thank the reviewer for the constructive suggestion. Modifications are made accordingly. We have not taken citation 6 from the Wikipedia page.

Methods, types of studies: Is it possible that the authors can include studies in languages they speak, which might include some languages other than English? This would be a major strength of the review if you could do this and found studies in your languages.
The authors completely agree with the reviewer on this point.

Methods, outcome measures: I think you need to describe the outcome measures more specifically. How would you measure suicide prevention and gatekeeper behaviour? And you may just need to specify what ‘knowledge’ and ‘attitude’ refer to…
Modifications are made accordingly.

Methods, hand searching – do you mean included studies, when you say primary studies? It might be better to say ‘included’ studies, as primary studies mean every bit of original research you find.
Modifications are made accordingly.

Study records, data management: You just need to cite EndNote: https://support.clarivate.com/Endnote/s/article/Citing-the-EndNote-program-as-a-reference?language=en_US
Modifications are made accordingly.

Data synthesis - What do you mean by the sensitivity and specificity of the included studies? Their ability to rule in and rule out what condition? What do you mean by ‘to track down the variables?’
Thank you for notifying me of this point. This paragraph is restructured.

Discussion – I’m not sure the first paragraph is necessary as it’d be good to talk about your review here.
We thank the reviewer for the kind suggestion. Modifications are made accordingly.

Extended data – you don’t need to include the PRISMA flow diagram at this stage.
The authors completely agree with the reviewer on this point.

Extended data – with the search terms, you just need to clarify if this is for PubMed?
Search terms are for all databases.

I think you might need to make the case for why this review is necessary, as I’m not sure it will find a lot of studies. You could say that previous reviews last searched the literature in February 2017 (Yonemato et al., 2019) and May 2018 (Torok et al., 2019), and you know that studies have been published since. Or maybe these reviews were limited to developed settings, although I don’t think this would be the case.
As per the authors’ knowledge, few reviews have been done to estimate the prevalence of suicide, and factors associated with suicide among students in South Asia. But this review will be done to determine the effectiveness of suicide prevention program (SPP) on the improvement of knowledge, attitude, and gatekeeper behaviour among gatekeepers in South Asian countries so that the number of suicide cases will be reduced among college students in South Asia countries.

Just related to PRISMA-P, I couldn’t see:

Who the guarantor is for the review : Corresponding author.

A statement on funding : Modification is made accordingly.

The section on outcomes and prioritization needs to discuss if any outcomes are primary and if any are secondary, and just describe the outcomes in more detail. I would see the PRISMA-P explanation and elaboration statement for an understanding of what you need to say here: http://www.bmj.com/content/349/bmj.g7647 : Modification is made accordingly.

You would need to talk about whether you wanted to assess meta-biases with, for example, a funnel plot for publication bias. I’d encourage seeing the E and E-statement on this item again: http://www.bmj.com/content/349/bmj.g7647 : Modification is made accordingly.
Competing Interests: No Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 29 Nov 2023

Tessy Treesa Jose, Psychiatric Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Udupi, 576104, India

29 Nov 2023

Author Response
Thank you for peer-reviewing our article.

Abstract, introduction: If the 703,000 figure is taken from WHO’s suicide estimates worldwide in 2019, it’s just 703,000 (not more), or you could ... Continue reading
Thank you for peer-reviewing our article.

Abstract, introduction: If the 703,000 figure is taken from WHO’s suicide estimates worldwide in 2019, it’s just 703,000 (not more), or you could say ‘over 700,000’.
The authors are thankful for your kind suggestion. As per the suggestions, modifications are carried out in the revised manuscript.

Abstract, introduction: What would be the reason for calling the intervention a suicide prevention program (SPP), rather than using the term ‘gatekeeper training’?
In the present systematic review, suicide prevention program (SPP) refers to any teaching intervention/program in the form of a workshop/ different methods of teaching/ module/booklet to gatekeepers on suicide prevention in college students. Therefore, the authors used the term “suicide prevention program”.

Abstract, methods: I think you don’t need to mention PICO here, as it is within PRISMA-P.
The authors completely agree with the reviewer on this point.

Abstract, methods: When mentioning ‘interventional studies’, you may need to specify study designs. Would these be any intervention study design, controlled or uncontrolled?
We thank the reviewer for this comment. In this review, the authors will include any interventional study designs (controlled and uncontrolled).

Abstract, methods: If looking purely at effectiveness, the authors may not need all these study quality assessment tools. For example, the MMAT may not be needed if the authors don’t plan to synthesise qualitative data.
Modification is done accordingly.

Introduction, first paragraph: You could probably say that suicide is a global public health issue, as it’s typically considered to be, rather than just a problem for psychiatry.
We would like to thank the reviewer for your kind suggestion. Modifications are made in the revised manuscript.

Introduction, first paragraph: Who does ‘today’s youth’ refer to? Is this in India or globally? Perhaps state where it ranks in the leading causes of death among these youth. The two sentences on youth may also need to be about all ages if this review does not look at gatekeeper interventions for youth specifically.
We thank the reviewer for this comment. This sentence is restructured.

Introduction, first paragraph: I’m not sure what is meant by a ‘weak psychological system’, but you need to revise the language here to make this term more technical.
We thank the reviewer for this comment. Modifications are made accordingly.

Introduction, second paragraph: The statement ‘The suicide rate is increasing every year’ is incorrect. WHO’s Global Health Estimates reported that ‘In the 20 years between 2000 and 2019, the global age-standardized suicide rate decreased by 36%’ -https://www.who.int/publications/i/item/9789240026643
We thank the reviewer for this comment. This sentence is removed from the revised manuscript.

Introduction, second paragraph: ‘The statement that 79% of the world’s suicide occurred in low and middle-income countries.’ Is a secondary citation in the document you cite. The primary citation is WHO data from 2016, and is actually 77% rather than 79%. I recommend instead citing https://www.who.int/publications/i/item/9789240026643. The updated figure for 2019 is 77%, the same as the 2016 figure but with a better citation.
We would like to thank the reviewer for your kind suggestion. Modifications are made accordingly.

Introduction, second paragraph: WISQARS would need to be referenced in the reference list. I understand that WISQARS is US only. You could instead cite the WHO global health estimates again, and paraphrase a statement like: ‘Suicide was the fourth leading cause of death in young people aged 15–29 years for both sexes’ https://www.who.int/publications/i/item/9789240026643. Reference 8 is a 2014 document, but is superseded now by these estimates.
We thank the reviewer for the valuable suggestion. Modifications are made accordingly.

Introduction, third paragraph: I think the first sentence of this just needs updating with the WHO report again. https://www.who.int/publications/i/item/9789240026643 It now looks like Sri Lanka has a higher rate for both sexes.
We thank the reviewer for the suggestion. India and Sri Lanka (12.9%) have the highest suicide rate in the Southeast Asia region.

Introduction, third paragraph: I think reference 13 is outdated now, and the WHO global estimates for 2019 should be used instead. With regards to reference 14, I think you should look at the most recent review of gatekeeper training to see if studies from South Asia were included, as that is most relevant to your review and justifies why this new review is necessary.
We thank the reviewer for the suggestion. Unfortunately, the authors could not find out the most recent reviews of gatekeeper training in South Asian Countries.
Reference 13 deals with the comparison of suicide rates between high-income countries and Asia whereas “Suicide Worldwide in 2019: Global Health Estimates” specifies a comparison between Africa, Europe, and Southeast Asia.

Introduction, fourth paragraph: Best to avoid the word ‘commits’ and say ‘dies by suicide’ instead.
Thank you for notifying me of this point. The text is modified as per the reviewer’s suggestion in the revised manuscript.

Introduction, fifth paragraph: It isn’t clear in the abstract that the review will be about college students only. Could you check that it is consistent? You also just need to cite citation 6 in the Wikipedia page, which is the Encyclopedia of Modern Asia.
We thank the reviewer for the constructive suggestion. Modifications are made accordingly. We have not taken citation 6 from the Wikipedia page.

Methods, types of studies: Is it possible that the authors can include studies in languages they speak, which might include some languages other than English? This would be a major strength of the review if you could do this and found studies in your languages.
The authors completely agree with the reviewer on this point.

Methods, outcome measures: I think you need to describe the outcome measures more specifically. How would you measure suicide prevention and gatekeeper behaviour? And you may just need to specify what ‘knowledge’ and ‘attitude’ refer to…
Modifications are made accordingly.

Methods, hand searching – do you mean included studies, when you say primary studies? It might be better to say ‘included’ studies, as primary studies mean every bit of original research you find.
Modifications are made accordingly.

Study records, data management: You just need to cite EndNote: https://support.clarivate.com/Endnote/s/article/Citing-the-EndNote-program-as-a-reference?language=en_US
Modifications are made accordingly.

Data synthesis - What do you mean by the sensitivity and specificity of the included studies? Their ability to rule in and rule out what condition? What do you mean by ‘to track down the variables?’
Thank you for notifying me of this point. This paragraph is restructured.

Discussion – I’m not sure the first paragraph is necessary as it’d be good to talk about your review here.
We thank the reviewer for the kind suggestion. Modifications are made accordingly.

Extended data – you don’t need to include the PRISMA flow diagram at this stage.
The authors completely agree with the reviewer on this point.

Extended data – with the search terms, you just need to clarify if this is for PubMed?
Search terms are for all databases.

I think you might need to make the case for why this review is necessary, as I’m not sure it will find a lot of studies. You could say that previous reviews last searched the literature in February 2017 (Yonemato et al., 2019) and May 2018 (Torok et al., 2019), and you know that studies have been published since. Or maybe these reviews were limited to developed settings, although I don’t think this would be the case.
As per the authors’ knowledge, few reviews have been done to estimate the prevalence of suicide, and factors associated with suicide among students in South Asia. But this review will be done to determine the effectiveness of suicide prevention program (SPP) on the improvement of knowledge, attitude, and gatekeeper behaviour among gatekeepers in South Asian countries so that the number of suicide cases will be reduced among college students in South Asia countries.

Just related to PRISMA-P, I couldn’t see:

Who the guarantor is for the review : Corresponding author.

A statement on funding : Modification is made accordingly.

The section on outcomes and prioritization needs to discuss if any outcomes are primary and if any are secondary, and just describe the outcomes in more detail. I would see the PRISMA-P explanation and elaboration statement for an understanding of what you need to say here: http://www.bmj.com/content/349/bmj.g7647 : Modification is made accordingly.

You would need to talk about whether you wanted to assess meta-biases with, for example, a funnel plot for publication bias. I’d encourage seeing the E and E-statement on this item again: http://www.bmj.com/content/349/bmj.g7647 : Modification is made accordingly.
Thank you for peer-reviewing our article.

Abstract, introduction: If the 703,000 figure is taken from WHO’s suicide estimates worldwide in 2019, it’s just 703,000 (not more), or you could say ‘over 700,000’.
The authors are thankful for your kind suggestion. As per the suggestions, modifications are carried out in the revised manuscript.

Abstract, introduction: What would be the reason for calling the intervention a suicide prevention program (SPP), rather than using the term ‘gatekeeper training’?
In the present systematic review, suicide prevention program (SPP) refers to any teaching intervention/program in the form of a workshop/ different methods of teaching/ module/booklet to gatekeepers on suicide prevention in college students. Therefore, the authors used the term “suicide prevention program”.

Abstract, methods: I think you don’t need to mention PICO here, as it is within PRISMA-P.
The authors completely agree with the reviewer on this point.

Abstract, methods: When mentioning ‘interventional studies’, you may need to specify study designs. Would these be any intervention study design, controlled or uncontrolled?
We thank the reviewer for this comment. In this review, the authors will include any interventional study designs (controlled and uncontrolled).

Abstract, methods: If looking purely at effectiveness, the authors may not need all these study quality assessment tools. For example, the MMAT may not be needed if the authors don’t plan to synthesise qualitative data.
Modification is done accordingly.

Introduction, first paragraph: You could probably say that suicide is a global public health issue, as it’s typically considered to be, rather than just a problem for psychiatry.
We would like to thank the reviewer for your kind suggestion. Modifications are made in the revised manuscript.

Introduction, first paragraph: Who does ‘today’s youth’ refer to? Is this in India or globally? Perhaps state where it ranks in the leading causes of death among these youth. The two sentences on youth may also need to be about all ages if this review does not look at gatekeeper interventions for youth specifically.
We thank the reviewer for this comment. This sentence is restructured.

Introduction, first paragraph: I’m not sure what is meant by a ‘weak psychological system’, but you need to revise the language here to make this term more technical.
We thank the reviewer for this comment. Modifications are made accordingly.

Introduction, second paragraph: The statement ‘The suicide rate is increasing every year’ is incorrect. WHO’s Global Health Estimates reported that ‘In the 20 years between 2000 and 2019, the global age-standardized suicide rate decreased by 36%’ -https://www.who.int/publications/i/item/9789240026643
We thank the reviewer for this comment. This sentence is removed from the revised manuscript.

Introduction, second paragraph: ‘The statement that 79% of the world’s suicide occurred in low and middle-income countries.’ Is a secondary citation in the document you cite. The primary citation is WHO data from 2016, and is actually 77% rather than 79%. I recommend instead citing https://www.who.int/publications/i/item/9789240026643. The updated figure for 2019 is 77%, the same as the 2016 figure but with a better citation.
We would like to thank the reviewer for your kind suggestion. Modifications are made accordingly.

Introduction, second paragraph: WISQARS would need to be referenced in the reference list. I understand that WISQARS is US only. You could instead cite the WHO global health estimates again, and paraphrase a statement like: ‘Suicide was the fourth leading cause of death in young people aged 15–29 years for both sexes’ https://www.who.int/publications/i/item/9789240026643. Reference 8 is a 2014 document, but is superseded now by these estimates.
We thank the reviewer for the valuable suggestion. Modifications are made accordingly.

Introduction, third paragraph: I think the first sentence of this just needs updating with the WHO report again. https://www.who.int/publications/i/item/9789240026643 It now looks like Sri Lanka has a higher rate for both sexes.
We thank the reviewer for the suggestion. India and Sri Lanka (12.9%) have the highest suicide rate in the Southeast Asia region.

Introduction, third paragraph: I think reference 13 is outdated now, and the WHO global estimates for 2019 should be used instead. With regards to reference 14, I think you should look at the most recent review of gatekeeper training to see if studies from South Asia were included, as that is most relevant to your review and justifies why this new review is necessary.
We thank the reviewer for the suggestion. Unfortunately, the authors could not find out the most recent reviews of gatekeeper training in South Asian Countries.
Reference 13 deals with the comparison of suicide rates between high-income countries and Asia whereas “Suicide Worldwide in 2019: Global Health Estimates” specifies a comparison between Africa, Europe, and Southeast Asia.

Introduction, fourth paragraph: Best to avoid the word ‘commits’ and say ‘dies by suicide’ instead.
Thank you for notifying me of this point. The text is modified as per the reviewer’s suggestion in the revised manuscript.

Introduction, fifth paragraph: It isn’t clear in the abstract that the review will be about college students only. Could you check that it is consistent? You also just need to cite citation 6 in the Wikipedia page, which is the Encyclopedia of Modern Asia.
We thank the reviewer for the constructive suggestion. Modifications are made accordingly. We have not taken citation 6 from the Wikipedia page.

Methods, types of studies: Is it possible that the authors can include studies in languages they speak, which might include some languages other than English? This would be a major strength of the review if you could do this and found studies in your languages.
The authors completely agree with the reviewer on this point.

Methods, outcome measures: I think you need to describe the outcome measures more specifically. How would you measure suicide prevention and gatekeeper behaviour? And you may just need to specify what ‘knowledge’ and ‘attitude’ refer to…
Modifications are made accordingly.

Methods, hand searching – do you mean included studies, when you say primary studies? It might be better to say ‘included’ studies, as primary studies mean every bit of original research you find.
Modifications are made accordingly.

Study records, data management: You just need to cite EndNote: https://support.clarivate.com/Endnote/s/article/Citing-the-EndNote-program-as-a-reference?language=en_US
Modifications are made accordingly.

Data synthesis - What do you mean by the sensitivity and specificity of the included studies? Their ability to rule in and rule out what condition? What do you mean by ‘to track down the variables?’
Thank you for notifying me of this point. This paragraph is restructured.

Discussion – I’m not sure the first paragraph is necessary as it’d be good to talk about your review here.
We thank the reviewer for the kind suggestion. Modifications are made accordingly.

Extended data – you don’t need to include the PRISMA flow diagram at this stage.
The authors completely agree with the reviewer on this point.

Extended data – with the search terms, you just need to clarify if this is for PubMed?
Search terms are for all databases.

I think you might need to make the case for why this review is necessary, as I’m not sure it will find a lot of studies. You could say that previous reviews last searched the literature in February 2017 (Yonemato et al., 2019) and May 2018 (Torok et al., 2019), and you know that studies have been published since. Or maybe these reviews were limited to developed settings, although I don’t think this would be the case.
As per the authors’ knowledge, few reviews have been done to estimate the prevalence of suicide, and factors associated with suicide among students in South Asia. But this review will be done to determine the effectiveness of suicide prevention program (SPP) on the improvement of knowledge, attitude, and gatekeeper behaviour among gatekeepers in South Asian countries so that the number of suicide cases will be reduced among college students in South Asia countries.

Just related to PRISMA-P, I couldn’t see:

Who the guarantor is for the review : Corresponding author.

A statement on funding : Modification is made accordingly.

The section on outcomes and prioritization needs to discuss if any outcomes are primary and if any are secondary, and just describe the outcomes in more detail. I would see the PRISMA-P explanation and elaboration statement for an understanding of what you need to say here: http://www.bmj.com/content/349/bmj.g7647 : Modification is made accordingly.

You would need to talk about whether you wanted to assess meta-biases with, for example, a funnel plot for publication bias. I’d encourage seeing the E and E-statement on this item again: http://www.bmj.com/content/349/bmj.g7647 : Modification is made accordingly.
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Reviewer Report 05 May 2023

Sheela Pavithran, Amrita College of Nursing, Amrita Institute of Medical Sciences, Kochi, Kerala, India

Approved

https://doi.org/10.5256/f1000research.145123.r170502

Title
How effective is Suicide Prevention Programme (SPP) in preventing suicide among college students?

The review
The authors have chosen an area of great concern to the present day - suicide among the adolescent/college students.

Objectives are clearly articulated in the review.

The study population, intervention and the outcomes are presented clearly

Authors have used an exhaustive search strategy and included all the major sources of evidence, a grey literature search and hand search ensured inclusion of all the relevant interventional studies that used SPP among gatekeepers to prevent suicide among the college students. This offers room for replication of the study too.

Conceptual homogeneity could be established by the statistical methods mentioned.

As the study is need of the hour - the escalating incidence of suicide among the youth, a focused intervention by the key gatekeepers as appropriate is necessary.

Based on the proposal presented here, the systematic review can b e approved.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Chemotherapy and Breast Cancer

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Author Response 29 Nov 2023

Tessy Treesa Jose, Psychiatric Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Udupi, 576104, India

29 Nov 2023

Author Response

Thank you for peer-reviewing our article. Titled “ Suicide prevention program (SPP) in South Asian Countries” is registered in PROSPERO.
Competing Interests: No
Thank you for peer-reviewing our article. Titled “ Suicide prevention program (SPP) in South Asian Countries” is registered in PROSPERO.
Thank you for peer-reviewing our article. Titled “ Suicide prevention program (SPP) in South Asian Countries” is registered in PROSPERO.
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Author Response 29 Nov 2023

Tessy Treesa Jose, Psychiatric Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Udupi, 576104, India

29 Nov 2023

Author Response

Thank you for peer-reviewing our article. Titled “ Suicide prevention program (SPP) in South Asian Countries” is registered in PROSPERO.
Competing Interests: No
Thank you for peer-reviewing our article. Titled “ Suicide prevention program (SPP) in South Asian Countries” is registered in PROSPERO.
Thank you for peer-reviewing our article. Titled “ Suicide prevention program (SPP) in South Asian Countries” is registered in PROSPERO.
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Version 2

VERSION 2 PUBLISHED 20 Apr 2023

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Sheela Pavithran, Amrita Institute of Medical Sciences, Kochi, India
Stuart Leske, The University of Queensland, Toowong, Australia
Katerina Kavalidou, University College Cork, Cork, Ireland

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24 Jul 2023 | for Version 2

Stuart Leske, UQ Poche Centre for Indigenous Health, The University of Queensland, Toowong, Queensland, Australia

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Approved

Thank you. I have reviewed the revised further and I have no further comments to make.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Suicide prevention research and systematic reviews.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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21 Jul 2023 | for Version 2

Katerina Kavalidou, National Suicide Research Foundation, University College Cork, Cork, County Cork, Ireland

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Approved With Reservations

Thank you for this well written protocol which will be helpful for mapping the evidence of suicide prevention programmes focused on college students in South Asian countries. It will be good if the authors can consider that suicide prevention programmes are not only helpful for preventing suicide deaths but also to support people who are experiencing suicidal thoughts and behaviours. So, beside the few minor issues that I am suggesting below, I would suggest to add the effectiveness of SPP for further outcomes, such as self-harm or suicidal ideation if possible. You could do this as secondary outcomes that you will focus on.

Best of luck with your work and looking forward to reading your systematic review results when they will be published.

Abstract:

As per my general comment above - In the Introduction you state ‘…so that the number of suicide cases will be reduced among college students…’. SPP can help reduce not only suicide deaths but behaviours, so I would not restrict your introduction and overall paper objective only on suicide deaths, which are rare in comparison to the suicidal behaviours.

Methods:

Outcome measures: the authors should mention how these measures will be assessed. Are they focusing on pre-post papers only and what type of analyses are they looking for, quantitative or qualitative or both?

Data synthesis: ‘…and how the suicide prevention program is effective in suicide prevention’. Better to rephrase this and maybe just say ‘and the effectiveness of suicide prevention programmes’.

Discussion: ‘Previous literature resulted that the suicide prevention program..’, better to have ‘presented’ or ‘highlighted’ instead of resulted.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Partly
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Suicide prevention, multimorbidity and hospital presented self-harm and suicide-related ideation.

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91 Views

10 May 2023 | for Version 1

Stuart Leske, UQ Poche Centre for Indigenous Health, The University of Queensland, Toowong, Queensland, Australia

91 Views Cite this report Responses(1)

Approved With Reservations

Yonemoto, N., Kawashima, Y., Endo, K., & Yamada, M. (2019). Implementation of gatekeeper training programs for suicide prevention in Japan: a systematic review. International journal of mental health systems, 13, 1-6.
Morton, M., Wang, S., Tse, K., Chung, C., Bergmans, Y., Ceniti, A., ... & Rizvi, S. (2021). Gatekeeper training for friends and family of individuals at risk of suicide: a systematic review. Journal of community psychology, 49(6), 1838-1871.
Torok, M., Calear, A. L., Smart, A., Nicolopoulos, A., & Wong, Q. (2019). Preventing adolescent suicide: A systematic review of the effectiveness and change mechanisms of suicide prevention gatekeeping training programs for teachers and parents. Journal of adolescence, 73, 100-112.
Nasir, B. F., Hides, L., Kisely, S., Ranmuthugala, G., Nicholson, G. C., Black, E., ... & Toombs, M. (2016). The need for a culturally-tailored gatekeeper training intervention program in preventing suicide among Indigenous peoples: a systematic review. BMC psychiatry, 16, 1-7.
Mo, P. K., Ko, T. T., & Xin, M. Q. (2018). School-based gatekeeper training programmes in enhancing gatekeepers’ cognitions and behaviours for adolescent suicide prevention: a systematic review. Child and adolescent psychiatry and mental health, 12, 1-24.
Burnette, C., Ramchand, R., & Ayer, L. (2015). Gatekeeper training for suicide prevention: A theoretical model and review of the empirical literature. Rand health quarterly, 5(1).
Isaac, M., Elias, B., Katz, L. Y., Belik, S. L., Deane, F. P., Enns, M. W., ... & Swampy Cree Suicide Prevention Team (12 members) 8. (2009). Gatekeeper training as a preventative intervention for suicide: a systematic review. The Canadian Journal of Psychiatry, 54(4), 260-268.
Holmes, G., Clacy, A., Hermens, D. F., & Lagopoulos, J. (2021). The long-term efficacy of suicide prevention gatekeeper training: a systematic review. Archives of suicide research, 25(2), 177-207.
Yonemoto, N., Kawashima, Y., Endo, K., & Yamada, M. (2019). Gatekeeper training for suicidal behaviors: A systematic review. Journal of affective disorders, 246, 506-514.

Who the guarantor is for the review
A statement on funding
The section on outcomes and prioritization needs to discuss if any outcomes are primary and if any are secondary, and just describe the outcomes in more detail. I would see the PRISMA-P explanation and elaboration statement for an understanding of what you need to say here: http://www.bmj.com/content/349/bmj.g7647
You would need to talk about whether you wanted to assess meta-biases with for example, a funnel plot for publication bias. I’d encourage seeing the E and E statement on this item again: http://www.bmj.com/content/349/bmj.g7647

Is the rationale for, and objectives of, the study clearly described?

Partly
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Partly
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Suicide prevention research and systematic reviews.

Respond to this report

Responses (1)

Author Response

29 Nov 2023

Tessy Treesa Jose, Psychiatric Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Udupi, 576104, India

Thank you for peer-reviewing our article.

Abstract, introduction: If the 703,000 figure is taken from WHO’s suicide estimates worldwide in 2019, it’s just 703,000 (not more), or you could say ‘over 700,000’.
The authors are thankful for your kind suggestion. As per the suggestions, modifications are carried out in the revised manuscript.

Abstract, introduction: What would be the reason for calling the intervention a suicide prevention program (SPP), rather than using the term ‘gatekeeper training’?
In the present systematic review, suicide prevention program (SPP) refers to any teaching intervention/program in the form of a workshop/ different methods of teaching/ module/booklet to gatekeepers on suicide prevention in college students. Therefore, the authors used the term “suicide prevention program”.

Abstract, methods: I think you don’t need to mention PICO here, as it is within PRISMA-P.
The authors completely agree with the reviewer on this point.

Abstract, methods: When mentioning ‘interventional studies’, you may need to specify study designs. Would these be any intervention study design, controlled or uncontrolled?
We thank the reviewer for this comment. In this review, the authors will include any interventional study designs (controlled and uncontrolled).

Abstract, methods: If looking purely at effectiveness, the authors may not need all these study quality assessment tools. For example, the MMAT may not be needed if the authors don’t plan to synthesise qualitative data.
Modification is done accordingly.

Introduction, first paragraph: You could probably say that suicide is a global public health issue, as it’s typically considered to be, rather than just a problem for psychiatry.
We would like to thank the reviewer for your kind suggestion. Modifications are made in the revised manuscript.

Introduction, first paragraph: Who does ‘today’s youth’ refer to? Is this in India or globally? Perhaps state where it ranks in the leading causes of death among these youth. The two sentences on youth may also need to be about all ages if this review does not look at gatekeeper interventions for youth specifically.
We thank the reviewer for this comment. This sentence is restructured.

Introduction, first paragraph: I’m not sure what is meant by a ‘weak psychological system’, but you need to revise the language here to make this term more technical.
We thank the reviewer for this comment. Modifications are made accordingly.

Introduction, second paragraph: The statement ‘The suicide rate is increasing every year’ is incorrect. WHO’s Global Health Estimates reported that ‘In the 20 years between 2000 and 2019, the global age-standardized suicide rate decreased by 36%’ -https://www.who.int/publications/i/item/9789240026643
We thank the reviewer for this comment. This sentence is removed from the revised manuscript.

Introduction, second paragraph: ‘The statement that 79% of the world’s suicide occurred in low and middle-income countries.’ Is a secondary citation in the document you cite. The primary citation is WHO data from 2016, and is actually 77% rather than 79%. I recommend instead citing https://www.who.int/publications/i/item/9789240026643. The updated figure for 2019 is 77%, the same as the 2016 figure but with a better citation.
We would like to thank the reviewer for your kind suggestion. Modifications are made accordingly.

Introduction, second paragraph: WISQARS would need to be referenced in the reference list. I understand that WISQARS is US only. You could instead cite the WHO global health estimates again, and paraphrase a statement like: ‘Suicide was the fourth leading cause of death in young people aged 15–29 years for both sexes’ https://www.who.int/publications/i/item/9789240026643. Reference 8 is a 2014 document, but is superseded now by these estimates.
We thank the reviewer for the valuable suggestion. Modifications are made accordingly.

Introduction, third paragraph: I think the first sentence of this just needs updating with the WHO report again. https://www.who.int/publications/i/item/9789240026643 It now looks like Sri Lanka has a higher rate for both sexes.
We thank the reviewer for the suggestion. India and Sri Lanka (12.9%) have the highest suicide rate in the Southeast Asia region.

Introduction, third paragraph: I think reference 13 is outdated now, and the WHO global estimates for 2019 should be used instead. With regards to reference 14, I think you should look at the most recent review of gatekeeper training to see if studies from South Asia were included, as that is most relevant to your review and justifies why this new review is necessary.
We thank the reviewer for the suggestion. Unfortunately, the authors could not find out the most recent reviews of gatekeeper training in South Asian Countries.
Reference 13 deals with the comparison of suicide rates between high-income countries and Asia whereas “Suicide Worldwide in 2019: Global Health Estimates” specifies a comparison between Africa, Europe, and Southeast Asia.

Introduction, fourth paragraph: Best to avoid the word ‘commits’ and say ‘dies by suicide’ instead.
Thank you for notifying me of this point. The text is modified as per the reviewer’s suggestion in the revised manuscript.

Introduction, fifth paragraph: It isn’t clear in the abstract that the review will be about college students only. Could you check that it is consistent? You also just need to cite citation 6 in the Wikipedia page, which is the Encyclopedia of Modern Asia.
We thank the reviewer for the constructive suggestion. Modifications are made accordingly. We have not taken citation 6 from the Wikipedia page.

Methods, types of studies: Is it possible that the authors can include studies in languages they speak, which might include some languages other than English? This would be a major strength of the review if you could do this and found studies in your languages.
The authors completely agree with the reviewer on this point.

Methods, outcome measures: I think you need to describe the outcome measures more specifically. How would you measure suicide prevention and gatekeeper behaviour? And you may just need to specify what ‘knowledge’ and ‘attitude’ refer to…
Modifications are made accordingly.

Methods, hand searching – do you mean included studies, when you say primary studies? It might be better to say ‘included’ studies, as primary studies mean every bit of original research you find.
Modifications are made accordingly.

Study records, data management: You just need to cite EndNote: https://support.clarivate.com/Endnote/s/article/Citing-the-EndNote-program-as-a-reference?language=en_US
Modifications are made accordingly.

Data synthesis - What do you mean by the sensitivity and specificity of the included studies? Their ability to rule in and rule out what condition? What do you mean by ‘to track down the variables?’
Thank you for notifying me of this point. This paragraph is restructured.

Discussion – I’m not sure the first paragraph is necessary as it’d be good to talk about your review here.
We thank the reviewer for the kind suggestion. Modifications are made accordingly.

Extended data – you don’t need to include the PRISMA flow diagram at this stage.
The authors completely agree with the reviewer on this point.

Extended data – with the search terms, you just need to clarify if this is for PubMed?
Search terms are for all databases.

I think you might need to make the case for why this review is necessary, as I’m not sure it will find a lot of studies. You could say that previous reviews last searched the literature in February 2017 (Yonemato et al., 2019) and May 2018 (Torok et al., 2019), and you know that studies have been published since. Or maybe these reviews were limited to developed settings, although I don’t think this would be the case.
As per the authors’ knowledge, few reviews have been done to estimate the prevalence of suicide, and factors associated with suicide among students in South Asia. But this review will be done to determine the effectiveness of suicide prevention program (SPP) on the improvement of knowledge, attitude, and gatekeeper behaviour among gatekeepers in South Asian countries so that the number of suicide cases will be reduced among college students in South Asia countries.

Just related to PRISMA-P, I couldn’t see:

Who the guarantor is for the review : Corresponding author.
A statement on funding : Modification is made accordingly.
The section on outcomes and prioritization needs to discuss if any outcomes are primary and if any are secondary, and just describe the outcomes in more detail. I would see the PRISMA-P explanation and elaboration statement for an understanding of what you need to say here: http://www.bmj.com/content/349/bmj.g7647 : Modification is made accordingly.
You would need to talk about whether you wanted to assess meta-biases with, for example, a funnel plot for publication bias. I’d encourage seeing the E and E-statement on this item again: http://www.bmj.com/content/349/bmj.g7647 : Modification is made accordingly.

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05 May 2023 | for Version 1

Sheela Pavithran, Amrita College of Nursing, Amrita Institute of Medical Sciences, Kochi, Kerala, India

92 Views Cite this report Responses(1)

Approved

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Chemotherapy and Breast Cancer

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Respond to this report

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Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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Suicide prevention program (SPP) in South Asian Countries: A protocol for systematic review

Abstract

Keywords

Introduction

Objective

Review question

Methods

Eligibility criteria

Information sources

Study records

Data items

Outcome and prioritization

Risk of bias in individual studies

Data synthesis

Confidence in cumulative evidence

Discussion

Ethics and dissemination

Strengths and limitations

Study status

Author contributions

Data availability

Underlying data

Extended data

Reporting guidelines

References

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