Keywords
self-harm; suicide; self-injury; recovery; facilitators; barriers; young people; adolescents; review; personally modifiable factor
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McEvoy D, Wilson C, Healy C et al. Identifying personally modifiable factors for self-harm recovery in young people: A protocol for a systematic review [version 1; peer review: awaiting peer review]. HRB Open Res 2025, 8:48 (https://doi.org/10.12688/hrbopenres.14123.1)
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Study Protocol
Identifying personally modifiable factors for self-harm recovery in young people: A protocol for a systematic review
[version 1; peer review: awaiting peer review]
PUBLISHED 04 Apr 2025
OPEN PEER REVIEW
REVIEWER STATUS
Abstract
Corresponding author:
David McEvoy
Competing interests:
No competing interests were disclosed.
Grant information:
Health Research Board-9610
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Copyright:
© 2025 McEvoy D 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: McEvoy D, Wilson C, Healy C et al. Identifying personally modifiable factors for self-harm recovery in young people: A protocol for a systematic review [version 1; peer review: awaiting peer review]. HRB Open Res 2025, 8:48 (https://doi.org/10.12688/hrbopenres.14123.1)
First published: 04 Apr 2025, 8:48 (https://doi.org/10.12688/hrbopenres.14123.1)
Latest published: 04 Apr 2025, 8:48 (https://doi.org/10.12688/hrbopenres.14123.1)
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Abbreviations
CHIME = a model of personal recovery which stands for connectedness; hope and optimism; identity; meaning and purpose empowerment;
CFIR = consolidated framework for implementation research;
MMAT = mixed methods appraisal tool
Introduction
Suicide is the third leading cause of death among young people aged 15–29 years globally1. A history of self-harm, whether the intention is suicidal or not, is one of the strongest predictors of a subsequent death by suicide2. Furthermore, the risk of a death by suicide increases with the number of self-harm episodes and the risk is higher in those aged 10–24 years compared to older age groups3,4. Worryingly, there have been indications from some countries that the prevalence of self-harm, particularly in young people, has increased during the last decade2. Self-harm in young people is therefore a serious public mental health challenge.
Self-harm is often seen as an invisible health challenge5. The majority of self-harm in the community goes unseen by clinical services6,7. Approximately 16–18% of adolescents report to have self-harmed in their lifetime8–11. Compared to other aspects of self-harm research, fewer studies have explored the processes of recovery for people who have self-harmed5,12. The Lancet Commission on self-harm (2024) mentions that discussions about self-harm should focus on relatable stories of survival, recovery and strategies, ideally from those with lived experience of self-harm2. However, even defining what is meant by ‘recovery from self-harm’ remains a challenge13.
Broadly speaking, self-harm recovery has been conceptualised in two ways: symptom-based recovery and personal recovery13. Symptom-based recovery is characterised by administering interventions aimed at diminishing symptoms linked to self-harm or reducing the act of self-harm itself13,14. Symptom-based recovery tends to be determined by a clinician, who is seen as an objective expert14. One definition of symptom-based (or clinical) recovery comprises full symptom remission (that is, self-harm cessation), the person being in education or work, independent living without formal carers, and engaging in social activities for a period of two years14.
Alternatively, personal recovery is subjective, multidimensional and can be signified by a person developing life satisfaction, irrespective of reducing mental health difficulties5,13. Lewin et al. describe a self-harm recovery model that is a non-linear process, characterised by “push and pull” motivators for engagement/reengagement and cessation/reduction5. Moreover, the self-harm recovery model is compared to more linear models in line with symptom-based (or clinical) recovery, which Lewin et al. argue are reductionist, whereby relapse is viewed as a failure of recovery rather than an embedded component5.
Self-harm behaviour has a very personal meaning to the individual and is one part of a myriad of different behaviours whereby the individual can express distress whilst experiencing overwhelming feelings15. Personal recovery can therefore be seen as a ‘journey of discovery’ upon which the individual embarks, and whereby the position of the clinician as ‘expert’ is replaced as a ‘collaborator’ with the individual in their quest to explore and co-construct a range of strategies for personal safety and well-being15. Personally modifiable factors are elements of a person’s lifestyle, skills, or behaviours that they have the direct ability to change or influence to improve their health or wellbeing and do not necessarily require a third party. Potential examples could include eating a good breakfast, getting sufficient sleep, or having a regular schedule or daily routine16. These factors are crucial to understand for both individuals on their recovery journeys and the clinicians who alongside them co-design strategies for recovery.
There is a paucity of research relating to the self-harm recovery processes; in particular in respect of personally modifiable factors for self-harm recovery in young people5,12. A meta-synthesis of qualitative research by Deering and Williams (2018) employed an acronym for examining activities that might facilitate personal recovery for self-harm in adults comprising of connectedness; hope and optimism; identity; meaning and purpose; and, empowerment (CHIME)13,17. Support groups, meditation, helping relationships, and online forums, in particular, were all highlighted as activities facilitating personal recovery13. A limitation from this meta-synthesis of qualitative data, however, is the subjectivity in how the activities were interpreted by participants to facilitate aspects of recovery, which may, as the authors suggest, contrast with trends that are objectively quantifiable over time13. Quantitative studies are much more likely to have longitudinal data and could provide insights into recovery and behaviour over-time. Given the challenge of youth self-harm, especially for the vast majority of cases that do not present at clinical services, there is a need for a systematic review to include quantitative studies, as well as qualitative studies, that have identified personally modifiable factors for recovery for young people who have self-harmed.
The primary aim of this systematic review is to identify personally modifiable factors for self-harm (symptom-based or personal) recovery in young people. The secondary aim is to identify the facilitators and barriers underpinning the implementation of personally modifiable factors for self-harm recovery in young people, if these have been identified in the included studies. Inductive coding will be used to identify the personally modifiable factors and the Consolidated Framework for Implementation Research (CFIR) will be used to analyse and summarise the barriers and facilitators to the implementation of these factors for recovery for self-harm in young people18. Personally modifiable factors will be categorised into those associated with either symptom-based or personal recovery if they are reported in a way that is possible. Personally modifiable factors associated with personal recovery will be further categorised into those associated with different aspects of this type of recovery, such as connecting with friends or gaining feelings of optimism or hopefulness about the future. Further stratifications will also be conducted based on the data from the included studies that could involve factors such as sex, sub-age groups, sociodemographic factors and other characteristics.
Methods
Study reporting and registration
We adopted the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) checklist for producing this protocol19. Please refer to Supplementary File 1 for the PRISMA-P checklist. This protocol was registered with PROSPERO (Prospero registration number: CRD420250650920)20.
Definitions
Self-harm is defined as intentional self-poisoning or injury, irrespective of the apparent purpose21. Self-harm involves a non-fatal initiation of an action where the intention may be suicidal or non-suicidal. Neither suicide death nor suicidal ideation, risk, threats or plans are included.
Youth is defined differently throughout the literature but typically includes people up to the age of 25 years22,23. Given that the systematic review will examine recovery process for self-harm in young people, the study also included people older than 25 years but who began self-harming as a young person (i.e., before the age of 25 years). Given that self-harm typically beings in early adolescence, young people are defined as people aged 10–25 years old for this study5,23,24.
Recovery in relation to self-harm include both symptom-based recovery and personal recovery as described and conceptualised in the introduction.
As mentioned previously, personally modifiable factors are elements of a person’s lifestyle, skills, or behaviours that the individual has the direct ability to change or influence to improve their health or wellbeing and do not necessarily require a third party. Potential examples could include exercising, journaling, eating well, meditating, or replacing the urge to self-harm with some other activity. Non-examples include past trauma, social class, a school wellness intervention programme, or medications (since they require prescriptions by a clinician) – none of which the individual has direct control. A psychotherapy intervention such as cognitive behavioural therapy (CBT) or dialectical behaviour therapy (DBT) would also not be deemed a personally modifiable factor since it requires the intervention by a trained professional. On the other hand, individual skills associated with these therapies, like distress tolerance or mindfulness, would be deemed personally modifiable factors since they can be implemented directly by the individual. Whilst the therapy given by a medical professional itself would not be deemed to be a personally modifiable factor, seeking help (like attending one’s GP) would be considered a personally modifiable factor since it is within the individual’s personal control to seek help.
Facilitators are factors that favour, facilitate, or help people to engage in personally modifiable factors, whereas barriers are factors that hinder, limit, or prevent people from engaging in personally modifiable factors25.
While inductive coding will be used to identify the personally modifiable factors, the Consolidated Framework for Implementation Research (CFIR) will be used to analyse and summarise the implementation determinants for these factors18. In particular, there are five macro components in CFIR that are included in the data extraction tools: individuals (the young people); the innovation (the personally modifiable factors for self-harm recovery); the implementation process (how the individuals can action the personally modifiable factors in their recovery journey); the inner setting (organisations that might influence implementation, such schools or health systems); and the outer setting (features of external context or environment that might influence implementation, such as government policy, social stigma, culture or economics)18,26.
Search strategy
The authors consulted with a librarian (GS) for the purposes of this search strategy. Five databases will be used for this systematic review: Medline (EBSCOHost), CINAHL(EBSCOhost), APA PsycInfo (EBSCOhost), Embase (Elsevier), and Web of Science (Core Collection). The search strategy was informed by the PICO (Population, intervention, comparison, outcome) format. The population are those that began self-harming as a young person. The intervention and comparison are the presence or absence, respectively, of the personally modifiable factors for self-harm. The outcome is recovery from self-harm in the broad sense of either symptom-based or personal recovery.
The search strategy originally involved five concepts: ‘young people’, ‘self-harm’, ‘personally modifiable factors’, ‘recovery’, and ‘implementation determinants (barriers and facilitators)’. Any paper including these implementation determinants would need to have identified the personally modifiable factor(s) to which they were referring. The set of papers addressing the secondary aim of this study (identifying barriers and facilitators) would therefore be a subset of the set of included studies addressing the primary aim of the study (identifying personally modifiable factors). We therefore did not include implementation determinants in our search strategy since it could potentially exclude papers addressing the primary aim of this study.
There was an extensive list of terms relating to recovery using both words associated with recovery itself and words using the CHIME taxonomy for personal recovery (comprising of connectedness; hope and optimism; identity; meaning and purpose; and, empowerment)13. See Supplementary File 2 for further details. Having consulted with a librarian (GS), it was found that a majority of papers ever published on Medline included terms relating to ‘recovery’ and therefore did not add much to the search strategy. Moreover, including the list of terms related to recovery (in Supplementary File 2) might only exclude relevant studies that used a different terminology for recovery not listed.
The search strategy outlined in Table 1, therefore, includes at least one word from each of three concepts: ‘young people’, ‘self-harm’, and ‘personally modifiable factors for recovery’. Note that Table 1 includes the specific syntax for Web of Science but the same word search was applied to the other databases with their respective syntax. The word ‘recovery’ is also included under ‘personally modifiable factors’ so that ‘personal recovery’ or ‘individual recovery’ will also be included in the search.
Table 1. Search terms for the systematic review and meta-analysis.
Finally, the search strategy will be conducted using the five databases from inception until a date in early 2025. The results from the five databases will be compiled together and exported to Covidence, a web-based collaboration software platform that streamlines the production of systematic reviews27.
Eligibility criteria
Primary (Title and abstract) Screening. After the results from the search process have been exported to Covidence, all duplicate results will be removed. Independent double screening will be used to assess each title and abstract for their eligibility for inclusion according to the primary screening criteria listed in Supplementary File 3. Any conflicts regarding their eligibility will be resolved by consensus with the other authors.
Studies that have identified one or more personally modifiable factors for recovery for young people who have self-harmed will be included in this review. These can be both qualitative or quantitative studies. As described previously, ‘recovery’, can be symptom-based and eligible studies for this review should include self-hep strategies for self-harm reduction or cessation. Studies examining personally modifiable factors for personal recovery may include factors that young people who have self-harmed can directly implement themselves that can lead to outcomes relating to connectedness; hope and optimism; identity; meaning and purpose; and, empowerment (i.e. CHIME). The terms for ‘recovery’ listed in Supplementary File 2 will be used to identify relevant papers. The quantitative studies will need to have utilised longitudinal cohort data to examine personally modifiable factors for recovery over time. Cross-sectional qualitative studies will be included but cross-sectional quantitative studies will be excluded.
Though the search strategy was designed specifically to include personally modifiable factors for recovery for people who have self-harmed, any studies pertaining to recovery for young people with general mental health difficulties will be included in this phase of screening since such studies may include young people who have self-harmed as an identifiable sub-group. Studies examining recovery from other specific psychiatric or non-psychiatric illnesses (bi-polar disorder or cancer, respectively) will be excluded. The search strategy was also designed specifically to include personally modifiable factors for recovery for young people but any studies that have examined all age groups will be included in this phase of screening. Studies specifically examining other age-groups (such as older people) that does not contain young people aged 10–25 years will be excluded.
Self-harm is conceptualised differently through the literature. Papers utilising terms like recovery from ‘suicidality’ will be included in primary screening. This often includes suicidal ideation as well as self-harm or self-injury. These papers will only be included in the secondary screening phase if self-harm or suicide attempts can be disentangled from other suicidality outcomes like suicidal ideation, plans or threats. As per the definition of self-harm used in this study, it must have involved a non-fatal initiation of an action. Studies specifically relating to recovery from suicidal ideation, threats or plans will not be included at this phase of screening.
Studies examining a larger intervention or programme for young people with a history of self-harm itself would not be considered to be a personally modifiable factor but such a study may identify a personally modifiable factor of interest to this study. To give a hypothetical example, a study examining a school-based mindfulness programme for recovery for young people with self-harm would be included in the primary screening phase. The school programme itself would not be considered to be a personally modifiable factor but it may infer that mindfulness is such a factor. Barriers and facilitators for mindfulness (e.g. difficulty in concentrating for people with attention or hyperactivity issues) would be relevant to this study but barriers and facilitators for introducing such a programme itself (e.g. an already busy school schedule or finance issues) would not be relevant. Therefore, such a study will be included in primary screening but it may be excluded at secondary screening.
Any relevant systematic reviews will be included in the primary screening phase. Moreover, studies that examined specific sub-populations defined by a specific characteristic such as sex, preferred gender, sexuality, ethnicity or a sociodemographic group etc. will be included.
Studies examining self-harm in relation to prevention, aetiology, epidemiology, or policy, will be excluded. Case reports, case series, non-English studies, grey literature, letters, conference abstracts and opinion pieces will all be excluded.
Secondary (Full paper) Screening. Similar to the primary screening phase, independent double screening will be used for the full-paper screening to assess their eligibility for inclusion according to the secondary screening criteria listed in Supplementary File 3. Any conflicts regarding their eligibility will be resolved by consensus with the other authors.
At this point any systematic reviews that have been included from the primary screening process will have their references checked and any relevant references will only be included if they meet the same inclusion/exclusion criteria as described before. These systematic reviews will then be excluded. Any studies that previously included all age groups in the primary screening phase will only be included if personally modifiable factors of ‘young people’ were specifically studied and identifiable as a sub-age-group. Otherwise, the study will now be excluded. Similarly, papers involving personally modifiable factors for recovery from mental health illness or outcomes related to self-harm, like suicidality, will only be included if they specifically examined young people who self-harmed as an identifiable subgroup.
Data extraction
Two separate data extraction tools will be used for qualitative and quantitative studies. These can be viewed in Supplementary File 4. Data extraction will be conducted by DME and another author will review all data extraction. Conflicts will be resolved by consensus with the other authors. These instruments will be used to record data extracted pertaining to both the primary and secondary aims of this study. Data that will be extracted for both types of studies will include the name of the lead author; the year of publication; the location of the study; the study design; the source of the data; study time-frame; the type of self-harm or how self-harm was defined; the sample size; and, the population studied. The quantitative studies will also include any effect sizes that have been calculated.
With respect to the primary review aim of identifying personally modifiable factors for self-harm recovery in young people, the studied personally modifiable factor(s) will be listed for each study. Furthermore, it may be the case that different personally modifiable factors may be associated with different definitions or types of recovery (e.g. cessation of self-harm or feeling empowered to managed difficult emotions). Therefore, within each row for each study in the data extraction tools, there will be sub-rows whereby each row will have a listed personally modifiable factor and a matching definition of recovery, which may or may not differ for each personally modifiable factor within the study.
The secondary aim of this study is to identify any barriers or facilitators for personally modifiable factors for self-harm recovery in young people, if these have been identified. Within each sub-row within each study row of the data extraction tools, data pertaining to barriers and facilitators will be listed within each of the five CFIR constructs. In addition, the sub-codes of these five constructs of CFIR will be used to analyse and summarise the barriers and facilitators in the data extraction columns.
Quality assessment
All studies that have been included in the secondary screening process will undergo a quality assessment. In particular, quality assessment will be conducted using the mixed methods appraisal tool (MMAT)28. The MMAT is a validated tool which allows for the methodological appraisal of quantitative, qualitative and mixed methods studies28. Given the variation in the conceptualisation of recovery from self-harm in the literature, and even in how self-harm itself is defined, it is anticipated that there will a high level of heterogeneity across included studies. Therefore, MMAT is an appropriate tool to use in this systematic review. Appraisals will be conducted by DME and, similar to the data extraction process, will be checked by another author. Any discrepancies will be resolved through consensus discussions with the other authors. MMAT evaluations will be displayed in a table summarising aggregated criterion ratings, accompanied by a descriptive narrative. Studies will not be excluded on the basis of their MMAT evaluations.
Data synthesis and reporting
The 2020 updated Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) statement will be used for reporting the systematic review29. A PRISMA flow diagram will be used to synthesise the screening process and the fundamental characteristics (locations, study designs, study durations etc.) of the included studies will be described. The studies will be classified into two major categories (qualitative and quantitative studies) and there may be further sub-categorisation needed, depending on the nature of the included studies.
In addressing the primary objective of this study, the identified personally modifiable factors will be categorised according to the definition of recovery to which they have been attributed. For secondary objective of identifying the facilitators and barriers for implementing personally modifiable factors for self-harm recovery in young people, these will be presented and discussed under the five constructs of the CFIR framework: namely, individuals, the process, intervention characteristics, inner setting, and, outer setting18. Furthermore, any sub-codes of the CFIR model will be discussed under each of the five headings18.
Statistical analysis
The completion of any meta-analyses may not be possible due to the heterogeneity of the studies that is anticipated given the varied definitions for recovery and the differences in the way it may be conceptualised. The possibility of completing a meta-analysis is conditioned on two or more studies having the same outcome for recovery, having the same personally modifiable factor attributed to that recovery outcome, and defining self-harm similarly. Furthermore, two or more studies would need to have reported the same type of effect size (hazard ratio, relative risk etc.). If this is possible, a pooled meta-analytic estimate (and the 95% confidence interval) will be calculated. Heterogeneity will be assessed using the I2 statistic. Publication bias will also be assessed using funnel plots.
Ethics and dissemination
Ethical approval is not needed for this review protocol. The results will be disseminated to academic audiences in a peer-reviewed journal and at academic conferences. The presentation of this study at academic conferences may take the form of poster presentations or oral presentations.
Discussion
The current study outlines a protocol for conducting a systematic review that will aim to identify personally modifiable factors for self-harm recovery and will inform young people who have self-harmed as well as their clinicians and/or close community of family and friends that may help them navigate their own recovery journey. Having been placed at the centre of their own recovery journey, these individuals can use these personally modifiable factors to charter their own recovery process and replace self-harm behaviour with safer and more sustainable coping strategies. Implementation science is a relatively new field and its aim is to integrate new research findings into routine care30. In particular, the use of the Consolidated Framework for Implementation Research (CFIR) to analyse and summarise the facilitators and barriers for implementing the identified personally modifiable factors in the systematic review will help researchers gain an understanding of how and why these personally modifiable factors succeed or fail31.
The conceptualisation of self-harm recovery is complicated and this protocol has outlined how recovery from self-harm in young people will broadly encompass both personal and symptom-based recovery. One key limitation is that self-harm recovery is a broad outcome and it is likely that there will be a great deal of heterogeneity between the studies in their various definitions of recovery rendering the completion of any meta-analysis unlikely, though not impossible.
Conclusion
Identifying and disseminating research on personally modifiable factors for self-harm recovery is important to help those exhibiting this behaviour to influence their own recovery process. This is especially important for young people, given their higher proportion of self-harm in comparison to other age cohorts. Furthermore, identifying the barriers and facilitators to implementing these personally modifiable factors could inform the design of effective public health interventions for reducing self-harm in young people, possibly reducing rates of youth suicide, for which self-harm is the most important predictor.
Ethics and consent
Ethical approval and consent were not required.
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McEvoy D, Wilson C, Healy C et al. Identifying personally modifiable factors for self-harm recovery in young people: A protocol for a systematic review [version 1; peer review: awaiting peer review]. HRB Open Res 2025, 8:48 (https://doi.org/10.12688/hrbopenres.14123.1)
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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