Context of implementation

The program has been implemented in Osakidetza, the Basque Health Service, represents one of the most advanced and well-funded public healthcare systems in Europe. What sets Osakidetza apart from other regional systems in Spain is its unique "Integrated Healthcare Organization" (OSI) model, which successfully breaks down the traditional barriers between primary care doctors and hospital specialists. By merging these two levels of care into single geographic management units, the system ensures that a patient's medical history and treatment plan flow seamlessly from their local neighborhood clinic to the most advanced surgical theaters.

BIZI Program was implemented within Osasun Eskola+ which is the official health education platform developed by Osakidetza to empower Basque citizens in the proactive management of their own health and well-being. Functioning as a "school of health," it shifts the focus from reactive medical treatment to a more preventive and educational approach. The platform provides a centralized, reliable repository of digital resources, including videos, infographics, and interactive guides, all designed to help patients and caregivers better understand various pathologies and healthy lifestyle habits. By offering evidence-based information that has been strictly vetted by medical professionals, it serves as a safe alternative to the often-unreliable health advice found through general internet searches.

The initiative is particularly vital for people living with chronic conditions, such as diabetes, heart disease, or respiratory issues, as it offers specialized programs that teach self-care techniques and symptom monitoring. One of the standout features of Osasun Eskola+ is its commitment to the "expert patient" model, which encourages individuals who have successfully managed their own conditions to share their experiences and support others within the community. This peer-to-peer learning environment, supported by professional clinical guidance, helps reduce the sense of isolation that often accompanies long-term illness and improves the overall quality of life for participants.

Accessibility is a core pillar of the platform, as it is fully integrated into the broader Osakidetza digital ecosystem and available in both Basque and Spanish. Beyond just providing static information, the service often facilitates webinars and workshops that cover topics ranging from mental health and emotional well-being to nutrition and physical activity. By providing these tools, Osakidetza aims to foster a more informed and autonomous society where the patient is no longer a passive recipient of care, but an active partner in the healthcare process, ultimately leading to better clinical outcomes and a more sustainable public health system.

Implementation goals

Regarding implementation BIZI degined two main goals:

1. Creation and usability analysis phase. 

2. Deployment throughout the territory.

Intersectoral collaboration and participation have been key elements. Suicide is a complex and multifactorial phenomenon and requires a multidimensional approach to tackle it. For this reason, a multidisciplinary and collaborative approach has been used, involving numerous entities from health, socio-health and community sectors. This broad approach is recognized in all phases of the project.

• The program was created by a multi-professional team including experts from different disciplines such as psychiatry, psychology, health communication and public health.
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• A usability analysis was carried out after its creation, involving 53 professionals who work in the community with groups vulnerable to suicide and who are therefore the target group of the initiative. Their comments and contributions on the clarity of the contents, etc. were incorporated into the program, resulting in the final version of Bizi.
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• The possibility of providing suggestions for improvement and other comments on the program has been kept open, both during the evaluation study and in the subsequent deployment phase, through an anonymous form included in the platform.  These contributions are collected and periodically analyzed.
• The recruitment for the evaluation study and the subsequent deployment phase was led by the Directorate of Public Health and carried out by the public health coordinators in the counties, who are the ones who best know the agents and resources in the territory, in collaboration with numerous entities and institutions. This is an indicative and non-exhaustive list.

Metrics / indicators used for evaluating the implementation

Methods used for evaluating the implementation

For he implementation phase a Process Evaluation was performed. Along the evaluation of the process the objective was to analyze the adequate completion of key actions in each of the three project stages, which make possible the successful development of the project.

• The three stages of the project for the analysis are:
• - Creation of the BIZI tool and Usability analysis.
• - Evaluation of impact on GTK competencies, satisfaction and adherence.

- Deployment of the program in the territory.

Implementation evaluation results

• Among other actors involved in the design of BIZI were: 
• Other Basque Government Departments (e.g. Social Services or Education)
• Provincial Councils (Gipuzkoa, Bizkaia and Araba)
• Local Administration, e.g. local police, social services or home help services (e.g. Municipality of Azpeitia https://azpeitia.eus/es/ )
• Official Associations (e.g. Pharmacy or Psychology Associations).
• Associations (e.g. Kolore Guztiak https://www.koloreguztiak.com/ ; Sirimiri: https://www.sirimiri.eus/ ; Agidap: http://www.agipad.org/ )
• NGOs (for example, Red Cross: https://www.cruzrojabizkaia.org/ or Caritas: https://www.caritasgipuzkoa.org/es/inicio )
• Companies for socio-occupational insertion (e.g. Gureak business group https://www.gureak.com/es/)

All stakeholders proviedd feedback on the program and the improvements on the usability analysis were introduced in the development of the program. The deployment in the territory was successful thanks to the involvement of the key stakeholders during the implementation plan and BIZI was successfully designed as a sustainable program. 

Outcome goals

BIZI program has also been evaluated by its effectiveness.  As an output objective the following was defined: To analyze the effect of the BIZI program on participants GTK competencies, and satisfaction. To analyze the adherence to the proposed contents.

For the impact evaluation, the defined objective was to analyze the real effect of training in early detection and referral of people at risk of suicide.

• The key indicator to be evaluated is % of those who complete the Bizi training who identify and refer someone at risk of suicide during the 6 months after the training (self-reported information by participants).

Metrics / indicators used for evaluating the outcomes

Methods used for evaluating the outcomes

The evaluation of the Bizi program includes Output and Impact evaluation. 

• Output Evaluation:
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• Adherence is a key aspect on which depends the success of self-managed and open access tools (time flexibility, lower costs and increased feasibility of deployment), as the potential advantages this format could be cancelled out by high drop-out rates.
• Design: Single group with repeated measures design (pre, immediate post and at 3 months). The pre and immediate post assessment is offered to all recruited participants, while the 3 months post assessment is offered only to participants recruited in the first 2 months.
• Study population and recruitment: The population of interest include non-health professionals and community volunteers working with groups vulnerable to suicide, as defined in the Suicide Prevention Strategy in the Basque Country (e.g. elderly population, homeless people, people with disabilities or in a situation of loneliness).

Exclusion criteria include to carry out clinical work in mental health or having previously received specific training in suicide prevention.

Recruitment lasts 6 months and it is carried out by the county coordinators of Public Health in the Basque Country, who send an invitation email to professionals and volunteers in their county whose profile fitted the defined criteria (e.g. social workers, pharmacists, educators, volunteers from associations of interest, etc.). All those who respond positively to the email receive a link to access the registration page of the program. After registration, the person can access the training platform.

• Evaluation of results:

There are five output variables. The first three correspond to three key GTK competencies identified in the literature (Yonemoto N. et al 2019; Burnette C. et al 2015) which include: Attitude towards suicidal behaviour, Self-efficacy in the face of a suicide risk situation and Knowledge about the phenomenon. The fourth variable is Satisfaction with the training and the fifth is Adherence to the program. The latter is defined as the percentage of all persons who started the training who completed 80% or more of the proposed activities.

The assessment instruments used to study the first four variables are online questionnaires included in the training platform:

• Attitude towards suicidal behaviour or degree to which the person considers it appropriate to intervene in the face of suicide risk. The 6 items of the Creencias Actitudinales sobre el Comportamiento Suicida (CCCS) questionnaire (Ruiz JA et al. 2005) will be used, which are rated on a 7 option Likert scale (1="Strongly disagree" to 7="Strongly agree"). The internal consistency of the instrument is α=.82 (Cronbach's Alpha).
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• Self-efficacy regarding suicidal behaviour or the degree to which the person feels competent to identify and provide help to a person at risk. This will be assessed by means of an ad hoc questionnaire created for this study based on a review of the literature. It consists of 5 items answered on a 5-option Likert scale from 1 (1="Strongly disagree" to 5="Strongly agree") and the internal consistency of the instrument is α=.74.
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• Knowledge about the suicide phenomenon or declarative knowledge about the suicide phenomenon, its prevention and the myths surrounding it. This was assessed by means of an ad hoc questionnaire created for this study based on a review of the literature and specific information relating to the epidemiological profile of suicide. It consists of 10 items that are scored as "true", "false" or "don't know, don't answer". The internal consistency of the instrument was α=.74.
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• Satisfaction: Overall satisfaction and perceived usefulness of the training will be assessed through two questions, "Could you rate overall the training you received (methodology, materials, practical usefulness, etc.)? Please rate from 1 to 10 with 1 being the lowest satisfaction and 10 being the highest satisfaction" and "Would you recommend this training to a colleague or in general to a non-health professional in contact with people vulnerable to suicide? Choose between: Yes very much, Yes somewhat, Don't know, No".
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• Data analysis

Mean scores obtained between pretest and immediate post test are compared using Student's t test. The effect size is calculated using Cohen's d. To analyze changes at the three-month follow-up, a one-factor analysis of variance with repeated measures is performed on the subsample of participants who perform this assessment. The effect size of the differences is estimated using Partial Eta Squared (η2p). To control for the error rate in multiple comparisons, Bonferroni correction is applied to the critical levels. All data analyses are carried out using IBM SPSS Statistics(V.26.0.).

• Impact Evaluation:

• Method: Anonymous questionnaire to be completed 6 months after the end of the course.
• The expected results is >10%.

Outcome evaluation results

The results of the evaluation study of the BIZI program demonstrate that it is the first GTK program in Spanish whose effectiveness in improving the attitude, self-efficacy, and knowledge of community workers in suicide prevention has been scientifically proven. Evaluation studies show significant improvements (P = 0.0001) with large effect sizes (d = 1.44) in participants’ self-confidence to identify and assist people at risk. Additionally, it also provides an increase in theoretical knowledge and the ability to demystify the phenomenon of suicide (d = 1.23). Long-term analyses show that the improvements achieved are sustained for at least three months afterward. Satisfaction among participants who complete the course is high, with a rating of 8.5 out of 10 and 100% of participants recommending the course to other professionals.