Ashley Hagaman, PhD, MPH

In LMIC, up to 20% of maternal deaths are due to suicide and in South Asia, suicide is a leading cause of death among women of reproductive age. Suicide is also highly stigmatized and a sensitive topic for community engagement. This research project uses a community-based co-design approach to explore the feasibility of engaging peer-volunteers in suicide detection and prevention in rural Pakistan, where findings will inform how task-shifted models for mental health care can successfully integrate suicide prevention practices, ultimately saving lives and improving community-based mental health services. Public health impacts may be substantial as results can be applied not only in similar South Asian contexts, but also in low-resourced settings in the US and abroad, where the suicide burden remains high.

We are a hub for innovation of original methodological contributions to advance the use of qualitative approaches, including elicitation, study design, and analysis, in implementation science through research, training, and collaboration. Our team of faculty, students, and implementers are working on various qualitative methods projects including the integration of rapid approaches for data collection and analysis, methods for human-centered design in complex field sites, and a scoping review of qualitative methods used in implementation science.

Three-quarters of suicide deaths occur in low and middle-income countries (LMICs). Despite recent calls to advance the research agenda surrounding suicide, there is a dearth of evidence supporting effective strategies for early identification and prevention in low-resourced, culturally diverse contexts. To respond to the lack of mental health services in LMIC, there has been rapid dissemination of task-shifted interventions (the redistribution of health tasks from specialized providers to low-level or community-level workers) to treat common mental disorders, but these lack suicide-specific protocols. Given the high mortality of suicide, there is critical and urgent need to incorporate implementation strategies for suicide risk detection and referral within these programs. This young investigator grant will provide expert mentoring in adapting and implementing task-shifted suicide prevention evidence-based practices in a low-income setting. This project is situated in Nepal, a member of the South–East Asian region that holds the largest proportion of the world’s suicides and some of the highest suicide rates. We propose to explore several multi-level strategies for suicide prevention that have growing evidence-base in LMIC (e.g., screening, safety planning, and brief intervention contact) and adapt and pilot the implementation of a suicide prevention package (SuPP) in a low-resource setting. Infrastructure for this research includes collaborators and staff at Kathmandu University’s Dhulikhel Hospital (KUDH), the community’s existing multilevel task-shifted intervention for depression, and mentor Dr. Lakshmi Vijayakumar’s expertise testing suicide prevention EBPs in India. We use mixed-methods to complete three aims: (1) explore the multilevel targets of a Suicide Prevention Package (SuPP) including health system, institutional, provider, and patient preferences for cultural adaptation and optimization; (2) Create the initial implementation toolkit and training manual for SuPP for health system implementation; and (3) Conduct a small open, non-randomized, pilot trial to assess the feasibility and acceptability of SuPP within the existing health system. To accomplish these aims we will use the Dynamic Adaptation Process (DAP)and EPIS framework (Exploration, Preparation, Implementation, Sustainment). Qualitative in-depth interviews (n=60) with health system stakeholders and staff, community counselors, and adults with lived experience of suicidal behavior (SB) will address Aim 1 (exploration phase). For Aim 2, the establishment of an Implementation Resource Team of health staff (IRT, n=12) at KUDH and a Community Advisory Board (n=15) of individuals and caretakers of mental health service users with lived experience of SB will guide a systematic adaptation of components included and implementation strategies for the Suicide Prevention Package (SuPP). Aim 3 will include an open pilot trial testing the implementation of SuPP in KUDH with 12 health workers (including 2 community counselors) and 25 enrolled eligible participants at risk for suicide. This project will inform how task-shifted models for mental health care can successfully integrate suicide prevention practices, ultimately saving lives and improving community-based mental health services. Our work will result in a suicide prevention package and adaptation process that can be utilized in diverse and disadvantaged settings around the world.

This multidisciplinary project, led by Joanna Maselko at Gillings School of Global Public Health, UNC-Chapel Hill, focuses on identifying the early childhood mechanisms through which maternal depression, and its treatment, shapes child developmental trajectories in rural Pakistan. We use transdisciplinary approaches, including economics, social epidemiology, psychiatry, and anthropology, to better understand how to make lasting improvements in maternal health, parental investments, and child development.

This interdisciplinary project is using a systems-integrated quality improvement approach to improve maternal and neonatal health services across Ethiopia. Our team uses mixed-methods to develop, test, and assess the impacts of patient care on mothers and their families.