Integrating a suicide prevention package of strategies into decentralized primary health care systems: an implementation pilot study in rural Nepal

PROJECT SUMMARY/ABSTRACT Suicide is a leading contributor to global mortality and rates have remained steady, or increased, in low- resourced settings. South Asia has the highest suicide rate in the world and despite different cultural risk profiles for suicide, little research has explored strategies for health systems to address its growing suicide burden. Given rising suicide rates and growing dissemination of mental health training programs for primary care health workers to treat common mental disorders (the WHO mental health gap action programme, mhGAP), there is critical and urgent need to incorporate implementation strategies for suicide detection, management and follow up within these programs. Community health workers remain an untapped resource to provide suicide prevention support in settings where it is needed most, particularly within overburdened health facilities. Using co-design principals and RE-AIM with primary health workers and a community advisory board, this project will assess barriers to implementing mhGAP suicide modules, then adapt and pilot test a package of strategies to optimize implementation within a decentralized primary care system in Nepal. We anticipate the primary care suicide prevention package (P-SuPP) will include more systematized screening with decision tool aids, the systematic integration of CHW task-shifted safety planning and contact follow-up, supportive supervision, and enhanced digital monitoring systems. The proposed research will in Aim 1 conduct a formative evaluation of current mhGAP suicide practices among clinicians and then co-develop and refine implementation protocols (including workflows, health worker training, and support standards) for integrating suicide detection and follow-up management (P-SuPP) to meet the needs of primary health providers. Aim 2 will complete a pilot feasibility hybrid type 2 randomized controlled trial (RCT) of P-SuPP versus standard mhGAP. We will use mixed-methods to assess trial feasibility and acceptability of implementing and sustaining P-SuPP. We will explore patient-level preliminary effectiveness outcomes including suicidality, depression, and uptake of follow-up care. We will also explore preliminary pilot RCT implementation outcomes including Reach, Adoption, Implementation, and Maintenance of P-SuPP at 6 months for a future fully powered trial. This R34 lays the groundwork for a future R01 to scale a package for suicide prevention strategies that can be integrated into government primary care facilities, particularly targeting individuals living in low-resourced settings. As the model is designed to be easily adapted and integrated, we anticipate the findings will be valuable for all researchers looking to improve population health and mental health services in disadvantaged settings.