Co-developing suicide prevention guidelines for Pakistan: a mixed-methods Delphi consensus study

Background
Suicide is a serious public health concern globally. Many suicide deaths occur in low- and-middle-income countries such as Pakistan, where the stigma related to mental health and suicidal behaviour is high, help-seeking is low, and availability of trained mental health professionals is limited. Community-based suicide prevention programmes such as suicide prevention first-aid guidelines are recognised as cost-effective approaches to strengthen the motivation of local partners within communities and lay public to act. However, there is no such evidence from Pakistan. Therefore, this study aimed to co-develop suicide prevention guidelines for gatekeepers to assist individuals in Pakistan experiencing suicidal ideation or behaviours. This will not only help to prevent or deter suicidal tendency among those experiencing suicidal thought/behaviours but also the stakeholders, especially mental health professionals.

Methods
This Delphi expert consensus study was conducted in two phases: (i) development of a semi-structured questionnaire aimed to develop suicide prevention guidelines. This involved compilation of statements from existing guidelines developed for similar context, followed by a one-day multi-disciplinary stakeholder consultation to review and contextualise each statement. The questionnaire with final statement was translated into Urdu. (ii) Phase 2 involved the Delphi process to co-produce contextually relevant consensus-based set of suicide prevention guidelines endorsed by a diverse panel of experts including expert by profession and expert by experience. Statements describing suicide prevention guideline were rated by the participants in two Delphi rounds, using in-person and online approaches.

Results
A total of 45 experts by profession and 27 lived experience experts from across Pakistan completed both rounds of Delphi. The initial compilation from existing guidelines led to a total of 460 statements, which increased to 564 statements after stakeholder consultation, to be rated in Round-1 of the Delphi. The total number of items describing guidelines accepted at Round-1 and 2 were 478. The statements are organised into eleven thematic sections, including the identification of suicide risk and its severity, initial support for individuals at risk, communication strategies for engaging with suicidal individuals, safety planning, and confidentiality protocols. Stakeholders recommended the inclusion of context-specific guidelines, such as recognising culturally relevant warning signs (e.g., verbal or behavioral expressions of feeling unloved or being forced into an unwanted marriage), advising first responders to adopt a friendly and non-judgmental tone, and assessing the urgency of intervention based on the individual’s mental health status.

Conclusion
The guidelines developed as result of this mixed-method research has successfully engaged stakeholder to contextualise guidelines for Pakistan such as by adding culturally appropriate examples of warning signs, methods used for self-harm and suicide, and reasons of self-harm etc. and Delphi survey to reach consensus. These guidelines co-adapted through consultations with experts by profession and experience will inform much needed public health initiatives to increase awareness and education and build capacity in a wide range of stakeholders across sectors for suicide prevention in Pakistan.

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