Inconvenient truths in suicide prevention: Why a Restorative Just Culture should be implemented alongside a Zero Suicide Framework

Adapting the Zero Suicide framework to the adult emergency department setting: Strategies for nurse leaders

The ED has been increasingly recognized as a key setting for suicide prevention. Zero Suicide (ZS) is an aspirational goal to eliminate suicide for all patients within a health care system through utilization of best practices. However, there has been limited exploration of ZS implementation within the ED. As ED nurses play an important role in suicide prevention through their close contact with patients at risk for suicide, ZS implementation would benefit from tailored strategies for ED nurse leadership. We describe the ZS framework and provides strategies for nurse leaders to adapt each ZS component in the adult ED.

Improving health system responses when patients are harmed: a protocol for a multistage mixed-methods study

INTRODUCTION

At least 10% of hospital admissions in high-income countries, including Australia, are associated with patient safety incidents, which contribute to patient harm ('adverse events'). When a patient is seriously harmed, an investigation or review is undertaken to reduce the risk of further incidents occurring. Despite 20 years of investigations into adverse events in healthcare, few evaluations provide evidence of their quality and effectiveness in reducing preventable harm.This study aims to develop consistent, informed and robust best practice guidance, at state and national levels, that will improve the response, learning and health system improvements arising from adverse events.

METHODS AND ANALYSIS

The setting will be healthcare organisations in Australian public health systems in the states of New South Wales, Queensland, Victoria and the Australian Capital Territory. We will apply a multistage mixed-methods research design with evaluation and in-situ feasibility testing. This will include literature reviews (stage 1), an assessment of the quality of 300 adverse event investigation reports from participating hospitals (stage 2), and a policy/procedure document review from participating hospitals (stage 3) as well as focus groups and interviews on perspectives and experiences of investigations with healthcare staff and consumers (stage 4). After triangulating results from stages 1-4, we will then codesign tools and guidance for the conduct of investigations with staff and consumers (stage 5) and conduct feasibility testing on the guidance (stage 6). Participants will include healthcare safety systems policymakers and staff (n=120-255) who commission, undertake or review investigations and consumers (n=20-32) who have been impacted by adverse events.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Northern Sydney Local Health District Human Research Ethics Committee (2023/ETH02007 and 2023/ETH02341).The research findings will be incorporated into best practice guidance, published in international and national journals and disseminated through conferences.

The implementation of a zero-suicide framework in a child and youth mental health service in Australia: processes and learnings

Suicide in children is a significant and growing problem. The "zero suicide" framework (ZSF) is one approach to suicide prevention used in health services for adults and children. This paper reports on the introduction of the first suicide prevention pathway (SPP) based on ZSF at a Child and Youth Mental Health Service (CYMHS) in Australia. It begins by describing the adaptations made to elements of the SPP originally designed for adults to meet the needs of children. Lessons learned in applying the SPP in the service are then discussed. The aim is to inform and improve practice in the use of zero suicide approaches in child and youth mental health settings in Australia and worldwide.

The process and perspective of serious incident investigations in adult community mental health services: integrative review and synthesis

AIMS AND METHOD

Serious incident management and organisational learning are international patient safety priorities. Little is known about the quality of suicide investigations and, in turn, the potential for organisational learning. Suicide risk assessment is acknowledged as a complex phenomenon, particularly in the context of adult community mental health services. Root cause analysis (RCA) is the dominant investigative approach, although the evidence base underpinning RCA is contested, with little attention paid to the patient in context and their cumulative risk over time.

RESULTS

Recent literature proposes a safety-II approach in response to the limitations of RCA. The importance of applying these approaches within a mental healthcare system that advocates a zero suicide framework, grounded in a restorative just culture, is highlighted.

CLINICAL IMPLICATIONS

Although integrative reviews and syntheses have clear methodological limitations, this approach facilitates the management of a disparate body of work to advance a critical understanding of patient safety in adult community mental healthcare.

Scoping Review of Restorative Justice in Academics and Medicine: A Powerful Tool for Justice Equity Diversity and Inclusion

Purpose

Restorative Justice (RJ) as a practice and mindset is growing within academic medicine and health care. The authors aim to categorize the extent to which RJ training and practices have been researched, explored, and applied within health care, medicine, and academic contexts.

Methods

In July 2021, the authors conducted a scoping literature review, searching four databases for peer-reviewed articles and book chapters discussing RJ. Authors also used bibliography searches and personal knowledge to add relevant work. Reviewers independently screened article titles and abstracts, assessing the full texts of potentially eligible articles with inclusion and exclusion criteria. From each included article, authors extracted the publication year, first author's country of origin, specific screening criteria met, and the depth with which it discussed RJ.

Results

From 599 articles screened, 39 articles, and books were included (published 2001-2021). Twenty-five (64%) articles discussed RJ theory with few describing application practices with substantial depth. Ten (26%) articles only referenced the term "restorative justice" and seven (18%) discussed legal applications in health care. Fifty-four percent were from outside the United States. Articles tended to describe RJ uses to address harm and often missed the opportunity to explore RJ's capacity to proactively build community and culture that helps prevent harm.

Conclusions

RJ in health care is a rapidly expanding field that offers a framework capable of building stronger communities, authentically preventing and responding to harm, inviting radical inclusion of diverse participants to build shared understanding and culture, and ameliorate some of the most toxic and unproductive hierarchical practices in academics and medicine. Most literature calls to RJ for help to respond to harm, although there are very few well-designed and evaluated implementations. Investment in RJ practices holds significant promise to steer our historically hierarchical, "othering" and imperfect systems to align with values of justice (vs. punishment), equity, diversity, and inclusion.

Systems Approach to Suicide Prevention: Strengthening Culture, Practice, and Education

Contemporary approaches to suicide prevention extend beyond an individual's interactions with care providers to seek opportunities for improvement in the wider care system. A systems-based analysis can yield opportunities to improve prevention and recovery across the care continuum. This article uses an example of an individual seeking care in an emergency department to show how a traditional clinical case formulation can be framed in terms of the outer and inner contexts of the EPIS (Exploration, Preparation, Implementation, Sustainment) framework to illuminate the impact of systemic factors on outcomes and to identify opportunities for improvement. Three mutually reinforcing domains (a culture of safety and prevention; best practices, policies, and pathways; and workforce education and development) of a systems approach to suicide prevention are outlined, along with their defining characteristics. A culture of safety and prevention requires engaged, informed leaders who prioritize prevention; lived experience integrated into leadership teams; and adverse events review in a Restorative Just Culture focused on healing and improvement. Best practices, policies, and pathways that promote safety, recovery, and health require codesign of processes and services and evolve through continuous measurement and improvement. To support a culture of safety and prevention, and caring, competent application of policy, organizations benefit from a longitudinal approach to workforce education. This includes a common framework and language; models clinical and lived experience collaboration; and supports continuous learning, as well as onboarding of new staff, rather than following a "one-and-done" approach, so that suicide prevention training remains top of mind across the workforce.

Proactive Detection (PROTECT) and Safety Planning to Shorten Emergency Department Stays for Psychiatric Patients

OBJECTIVE

A literature gap exists for interventions to decrease average length of stay (ALOS) for patients with psychiatric presentations at the emergency department (ED). Long ALOSs are often related to sequential assessments of patients with high suicide risk or patients awaiting an inpatient bed. Safety planning may provide opportunities for diverting patients to the community and for reducing ED ALOS. This study reports on the impact of a safety-planning approach based on the PROTECT (proactive detection) framework for suicide prevention.

METHODS

A complex intervention (comprising leadership, governance, and innovation) was instrumental in embedding a new clinical culture of proactive detection and positive risk management through safety planning at Princess Alexandra Hospital in Brisbane, Queensland, Australia. Practice as usual continued at a comparator nonintervention site (NIS). In total, 24,515 psychiatric presentations over 24 months were grouped into monthly averages for key outcomes, providing a sample size of 24 at each site. A difference-in-differences analysis across sites, preintervention (January-November 2019) and postimplementation (December 2019-December 2020), was used to estimate the intervention's impact.

RESULTS

ED ALOS for psychiatric presentations, patients with an ALOS >12 hours, patients with an ALOS >24 hours, and inpatient psychiatric admissions decreased significantly compared with NIS (p<0.01) pre- and postimplementation of the safety-planning intervention.

CONCLUSIONS

Embedding a recovery-oriented culture of safety significantly reduced ED ALOS for psychiatric evaluations. Leadership, governance, and innovative practices that shift the focus of assessment and care from a mindset of risk prediction to one of prevention through collaborative safety planning as outlined in the PROTECT framework may have far-reaching benefits for patient care.

Implementation of Suicide Risk Estimation Analytics to Support Mental Health Care for Quality Improvement

This quality improvement study describes use of estimation analytics to augment existing suicide prevention practices during routine mental health specialty encounters at a large US health care system.

The Paradox of Suicide Prevention

The recognition that we cannot use risk stratification (high, medium, low) to predict suicide or to allocate resources has led to a paradigm shift in suicide prevention efforts. There are challenges in adapting to these new paradigms, including reluctance of clinicians and services to move away from traditional risk categorisations; and conversely, the risk of a pendulum swing in which the focus of care swings from one approach to determining service priority and focus (e.g., diagnosis, formulation, risk and clinical care) to a new focus (e.g., suicide specific and non-clinical care), potentially supplanting the previous approach. This paper argues that the Prevention Paradox provides a useful mental model to support a shift in paradigm, whilst maintaining a balanced approach that incorporates new paradigms within the effective aspects of existing ones. The Prevention Paradox highlights the seemingly paradoxical situation where the greatest burden of disease or death is caused by those at low to moderate risk due their larger numbers. Current planning frameworks and resources do not support successful or sustainable adoption of these new approaches, leading to missed opportunities to prevent suicidal behaviours in healthcare. Adopting systems approaches to suicide prevention, such as the Zero Suicide Framework, implemented in a large mental health service in Australia and presented in this paper as a case study, can support a balanced approach of population- and individual-based suicide prevention efforts. Results demonstrate significant reductions in re-presentations with suicide attempts for consumers receiving this model of care; however, the increasing numbers of placements compromise the capacity of clinical teams to complete all components of standardised pathway of care. This highlights the need for review of resource planning frameworks and ongoing evaluations of the critical aspects of the interventions.

Psychiatrists' Experience of a Peer Support Group for Reflecting on Patient Suicide and Homicide: A Qualitative Study

There is a lack of support for mental health professionals who experience a patient suicide or homicide. This is despite a high likelihood of such an occurrence and the heavy professional and personal toll the experience can take. We conducted 15 interviews with members of a facilitated peer support group run for consultant psychiatrists who have experienced a patient homicide or suicide. Our interviews explored the trauma of the experience as well as the effectiveness of the group in helping the clinician heal. Our results echoed previous research that the experience can be profoundly traumatic. A professionally facilitated, consultant-only peer group specifically dedicated to suicide and homicide were the key components helping participants to process their grief. Mental health trusts should consider setting up facilitated peer support groups for clinicians who experience patient suicide or homicide.

Establishing a Guide for Developing Organizational Support in Healthcare Following a Critical or Sentinel Event

Health professionals require support and recognition to help manage the well-known impact of critical or sentinel events relating to patient care. The potential distress can be magnified or mitigated by the response of the organization and colleagues. However, strategies that are accessible, relevant, and effective in the aftermath of a poor outcome are not well established. Using an action research methodology, a support tool was collaboratively designed, developed, and evaluated in a maternity service of one organization and adapted to the mental health and addiction service in another. Four principles that are intrinsic to the establishment of support tools became apparent across the two settings. Through applying these criteria to the customization of the support tool, it became relevant within the new service setting, and an implementation guide for other organizations was created. Although undertaken pre-pandemic, insights derived from this study may benefit post-pandemic situations where the need for health professional support is even greater.

Shared understanding of resilient practices in the context of inpatient suicide prevention: a narrative synthesis

Background

The prevailing patient safety strategies in suicide prevention are suicide risk assessments and retrospective reviews, with emphasis on minimising risk and preventing adverse events. Resilient healthcare focuses on how everyday clinical practice succeeds and emphasises learning from practice, not from adverse events. Yet, little is known about resilient practices for suicidal inpatients. The aim of the study is to draw upon the perspectives of patients and healthcare professionals to inform the conceptual development of resilient practices in inpatient suicide prevention.

Methods

A narrative synthesis was conducted of findings across patients and healthcare professionals derived from a qualitative case study based on interviews with patients and healthcare professionals in addition to a systematic literature review.

Results

Three sub-themes categorise resilient practices for healthcare professionals and for patients hospitalised with suicidal behaviour: 1) interactions capturing non-verbal cues; 2) protection through dignity and watchfulness; and 3) personalised approaches to alleviate emotional pressure. The main theme, the establishment of relationships of trust in resilient practices for patients in suicidal crisis, is the foundation of their communication and caring.

Conclusion

Clinical practice for patients hospitalised with suicidal behaviour has characteristics of complex adaptive systems in terms of dynamic interactions, decision-making under uncertainty, tensions between goals solved through trade-offs, and adaptations to patient variability and interpersonal needs. To improve the safety of patients hospitalised with suicidal behaviour, variability in clinical practice should be embraced.

Trial registration

https://doi.org/10.1136/bmjopen-2016-012874

Newtonian science, complexity science and suicide-critically analysing the philosophical basis for suicide research: A discussion paper

AIM

A critical discussion comparing Newtonian science and complexity science as the philosophical basis for suicide research and its impact on suicide knowledge development and clinical practice.

DESIGN

Discussion paper.

DATA SOURCES

A review of literature on suicide research and complexity science ranging from 2000 to 2022.

IMPLICATIONS FOR NURSING

Suicide research based on a Newtonian worldview can have negative consequences for suicide knowledge development and can permeate nursing practice in ways that take away from addressing the complex needs of patients, their families and healthcare teams.

CONCLUSION

A Newtonian worldview as a philosophical basis for research is insufficient for the study of a phenomenon as complex as suicide. A complexity science approach is better suited to the study of suicide given the multiple, interrelated, emerging factors that can contribute to a person's decision to end their own life.

IMPACT

Suggestions are provided as to how a complexity science approach to the research of suicide can inform useful knowledge development that better meets the needs of individuals facing suicidality and their families. Researchers, healthcare administrators and nurses providing care to those struggling with suicidality can benefit from adopting a complexity science worldview in addressing this multifaceted phenomenon.

Towards Zero Suicide: need and opportunities to improve implementation of clinical elements for older adults

OBJECTIVE

The Zero Suicide (ZS) framework is increasingly used in Australia, but without published adaptations for older people, and limited access by older people when implemented. The aim of this paper is to inform Towards Zero Suicide (TZS) implementations to benefit older adults by considering the key differences in older adults at risk of suicide according to each clinical component of the ZS framework.

CONCLUSION

TZS aspires to reduce deaths by suicide for people within healthcare by refocusing interventions on suicidality rather than diagnosis alone, emphasising evidence-based practices and cultural change. For TZS to be effective for older people, it is essential to ensure practices are based upon evidence relevant to older people and to ensure ageism is effectively counteracted. Older adults have distinct patterns of help seeking and service use, accompanied by differences in risk factors, presentations, and outcomes of suicidal behaviours. Ageism affects assessment, decision-making and actions to address self-harm and suicide for older people. Immediate and longer-term actions are essential to effectively implement TZS in this population.

Improving Suicide Prevention in Primary Care for Differing Levels of Behavioral Health Integration: A Review

Importance

Suicide prevention implementation in primary care is needed due to the increasing rate of suicide in the past few decades, particularly for young and marginalized people. Primary care is the most likely point of contact for suicidal patients in the healthcare system. Attention to the level of medical integration with behavioral health is vital to suicide prevention and is applied throughout this review.

Methods

A narrative review was performed.

Observations

Many interventions help improve suicide prevention care. PCP education, screening, safety planning/lethal means reduction, care transitions, psychotherapy, and medication management are all evidence-based strategies. Additionally, the pragmatic topics of financing suicide prevention, supporting providers, enacting suicide postvention, and preparing for future directions in the field at each level of primary care/behavioral health integration are discussed.

Conclusions and Relevance

The findings are clinically relevant for practices interested in implementing evidence-based suicide prevention strategies by attending to the behavioral health/medical interface. Leveraging the patient/provider relationship to allow for optimal suicide prevention care requires clinics to structure provider time to allow for emotionally present care. Defining clear roles for staff and giving attention to provider well being are also critical factors to supporting primary care-based suicide prevention efforts.

Humanizing harm: Using a restorative approach to heal and learn from adverse events

Background

Healthcare is not without risk. Despite two decades of policy focus and improvement efforts, the global incidence of harm remains stubbornly persistent, with estimates suggesting that 10% of hospital patients are affected by adverse events.

Methods

We explore how current investigative responses can compound the harm for all those affected—patients, families, health professionals and organizations—by neglecting to appreciate and respond to the human impacts. We suggest that the risk of compounded harm may be reduced when investigations respond to the need for healing alongside system learning, with the former having been consistently neglected.

Discussion

We argue that incident responses must be conceived within a relational as well as a regulatory framework, and that this—a restorative approach—has the potential to radically shift the focus, conduct and outcomes of investigative processes.

Conclusion

The identification of the preconditions and mechanisms that enable the success of restorative approaches in global health systems and legal contexts is required if their demonstrated potential is to be realized on a larger scale. The policy must be co‐created by all those who will be affected by reforms and be guided by restorative principles.

Patient or Public Contribution

This viewpoint represents an international collaboration between a clinician academic, safety scientist and harmed patient and family members. The paper incorporates key findings and definitions from New Zealand's restorative response to surgical mesh harm, which was co‐designed with patient advocates, academics and clinicians.

Collaborative Approach to Supporting Staff in a Mental Healthcare Setting: "Always There" Peer Support Program

This paper describes the development and implementation of a peer-support program Always There in a large public mental health service in Queensland, Australia. The program is modelled on Scott's three tier model of peer support, with trained responders providing emotional support to staff following a traumatic adverse event, or when experiencing acute or cumulative stress. Support is provided in complete confidentiality. Main lessons learned in the 2 years since the launch of the program are shared in this paper, outlining successes such as improvements in staff's perception of organisational culture, and challenges related to embedding the program to "business as usual".

Consumer and Carer Perspectives of a Zero Suicide Prevention Program: A Qualitative Study

This study explored the experiences of healthcare consumers who had recently attempted suicide, and their carers, following placement on a Suicide Prevention Pathway based on the Zero Suicide framework. Qualitative interviews were conducted with 10 consumers and 5 carers using a semi-structured interview schedule. Interviews were transcribed and thematic analysis was applied to identify prominent themes and sub-themes. Three interrelated themes were identified. The first theme was 'Feeling safe and valued' with the associated sub-theme pertaining to perceived stigmatizing treatment and self-stigma. The second was 'Intersection of consumer and staff/organizational needs' with a related sub-theme of time pressure and reduced self-disclosure. The final theme was 'Importance of the 'whole picture', highlighting the relevance of assessing and addressing psychosocial factors when planning for consumer recovery. Overall, consumers and their carers reported a favorable experience of the Suicide Prevention Pathway; however, there were several areas identified for improvement. These included reconciling the time-pressures of a busy health service system, ensuring consumers and carers feel their psychosocial concerns are addressed, and ensuring that adequate rapport is developed. Key to this is ensuring consumers feel cared for and reducing perceptions of stigma.

Efficacy of the Zero Suicide framework in reducing recurrent suicide attempts: cross-sectional and time-to-recurrent-event analyses

BACKGROUND

The Zero Suicide framework is a system-wide approach to prevent suicides in health services. It has been implemented worldwide but has a poor evidence-base of effectiveness.

AIMS

To evaluate the effectiveness of the Zero Suicide framework, implemented in a clinical suicide prevention pathway (SPP) by a large public mental health service in Australia, in reducing repeated suicide attempts after an index attempt.

METHOD

A total of 604 persons with 737 suicide attempt presentations were identified between 1 July and 31 December 2017. Relative risk for a subsequent suicide attempt within various time periods was calculated using cross-sectional analysis. Subsequently, a 10-year suicide attempt history (2009-2018) for the cohort was used in time-to-recurrent-event analyses.

RESULTS

Placement on the SPP reduced risk for a repeated suicide attempt within 7 days (RR = 0.29; 95% CI 0.11-0.75), 14 days (RR = 0.38; 95% CI 0.18-0.78), 30 days (RR = 0.55; 95% CI 0.33-0.94) and 90 days (RR = 0.62; 95% CI 0.41-0.95). Time-to-recurrent event analysis showed that SPP placement extended time to re-presentation (HR = 0.65; 95% CI 0.57-0.67). A diagnosis of personality disorder (HR = 2.70; 95% CI 2.03-3.58), previous suicide attempt (HR = 1.78; 95% CI 1.46-2.17) and Indigenous status (HR = 1.46; 95% CI 0.98-2.25) increased the hazard for re-presentation, whereas older age decreased it (HR = 0.92; 95% CI 0.86-0.98). The effect of the SPP was similar across all groups, reducing the risk of re-presentation to about 65% of that seen in those not placed on the SPP.

CONCLUSIONS

This paper demonstrates a reduction in repeated suicide attempts after an index attempt and a longer time to a subsequent attempt for those receiving multilevel care based on the Zero Suicide framework.

Analysis of Suicides Reported as Adverse Events in Psychiatry Resulted in Nine Quality Improvement Initiatives

Background: The majority of persons who die by suicide have a mental disorder. Preventive strategies should include addressing social and psychological factors and the treatment of the mental disorder. Aim: We aimed to identify breaches in clinical care and identify areas for quality improvement initiatives. Method: An aggregate analysis of suicides reported as adverse events during 2012-2016 to Psychiatry, North Denmark Region was carried out. We developed an audit chart and identified items through (a) medical chart review and (b) consensus meetings in an expert panel. Results: A total of 35 cases were analyzed. Suicide risk assessments were adequately documented in the medial chart in six of 35 cases. Risk assessments emphasized suicidal ideation rather than well-known risk factors such as previous suicide attempts, substance abuse, physical illness, or job loss. Relatives were involved in four of 35 of the risk assessments. The panel suggested nine areas for quality improvement. Limitations: Most people who die by suicide are not seen in mental health facilities prior to suicide, and hence conclusions can only be generalized to these patients. Information on the gap between "Work-as-Done" and "Work-As-Imagined" was not recognized. Conclusion: Most of the risk assessments among suicides reported as adverse events to our mental health facilities were insufficient. Quality improvement initiatives focusing on training, documentation, involving relatives, communication, and data sharing must be planned to improve clinical care.

Implementing a systems approach to suicide prevention in a mental health service using the Zero Suicide Framework

OBJECTIVE

The Zero Suicide Framework, a systems approach to suicide prevention within a health service, is being implemented across a number of states in Australia, and internationally, although there is limited published evidence for its effectiveness. This paper aims to provide a description of the implementation process within a large health service in Australia and describes some of the outcomes to date and learnings from this process.

METHOD

Gold Coast Mental Health and Specialist Services has undertaken an implementation of the Zero Suicide Framework commencing in late 2015, aiming for high fidelity to the seven key elements. This paper describes the practical steps undertaken by the service, the new practices embedded, emphasis on supporting staff following the principles of restorative just culture and the development of an evaluation framework to support a continuous quality improvement approach.

RESULTS

Improvements have been demonstrated in terms of processes implementation, enhanced staff skills and confidence, positive cultural change and innovations in areas such as the use of machine learning for identification of suicide presentations. A change to 'business as usual' has benefited thousands of consumers since the implementation of a Suicide Prevention Pathway in late 2016 and achieved reductions in rates of repeated suicide attempts and deaths by suicide in Gold Coast Mental Health and Specialist Services consumers.

CONCLUSION

An all-of-service, systems approach to suicide prevention with a strong focus on cultural shifts and aspirational goals can be successfully implemented within a mental health service with only modest additional resources when supported by engaged leadership across the organisation. A continuous quality improvement approach is vital in the relentless pursuit of zero suicides in healthcare.

The state of psychiatric research in the Asia Pacific region

INTRODUCTION

This study aims to review recent scientific publications and research output in the field of psychiatry, from a series of countries in the Asia-Pacific region (Australia, India, Indonesia, Iran, Lebanon, Malaysia, and Nepal), with a view to identify themes and similarities across regions, as well as to examine the barriers and challenges in mental health research faced by countries in the region.

METHODS

Seven psychiatrists from seven countries reviewed recent published and ongoing research in psychiatry in their respective nations, with respect to themes, as well as any barriers or challenges faced by mental health researchers.

RESULTS

While the seven nations included in this review vary in terms of research capabilities and economic development level, they share many similarities both in terms of research direction, and with regards to challenges faced. Limitations in the form of sociocultural differences from the West, and a lack of funding were some of the barriers identified.

DISCUSSION

Mental health research in the region has been progressing well. However, more varied research in the form of qualitative or economic studies are lacking, as are multi-center studies. The similar issues that nations face with regards to research could perhaps benefit from collaborative efforts and initiatives for the furtherance of research in the region.