This study is the first to assess perceptions of stakeholders on the research priorities needed to inform and support suicide prevention in Nepal. This study has highlighted that research in this field is at a very early stage and hence, baseline studies to measure ways to improve the quality of suicide data, assess the burden of suicide, factors associated with it, status of suicide response system and support needs of patients and their family members are deemed necessary.
The development of a comprehensive patient data collection system, such as real-time surveillance, death record linkage, and patient registries is proposed as the first step in this process, which have the potential to facilitate later steps in a research infrastructure designed to test various interventions efficiently . In Nepal, as well as many South Asian countries, there is a lack of a comprehensive vital registration system . National level suicide data are not systematically collected, and suicide mortality data are not reported by the WHO, but rather, are estimated [2, 22, 35, 36]. As suicide data are ‘owned’ by the police force in Nepal, there will need to be coordination and communication between the law enforcement and health systems in order to produce accurate estimates of suicide data . Study participants were clear that putting robust systems in place to capture quality data is the fundamental challenge which needs to be addressed in Nepal. Future studies can focus on projects such as developing and piloting comprehensive surveillance systems for recording suicide and attempted suicides, and utilizing data from community surveillance systems, hospital and police records.
In the absence of accurate data on suicide in Nepal, our study experts expressed the need for a high quality nationally representative research programme on suicide and its causes. This resonates with studies from more developed countries that have called for studies of suicide prevention intervention in large samples, marginal groups and outpatients as research priorities to enhance patient safety . In an Australian study reporting stakeholder’s views on future suicide prevention research, expert participants ranked evaluation studies assessing the efficacy of interventions, policies and programs most highly, followed by epidemiological studies of suicidal individual risk and protective factors . In the current study, participants ranked the relative importance of research assessing risk factors (such as, previous suicidal attempt, family history of suicide etc.,) and protective factors (such as people’s capacity for resilience, hope and optimism) for suicide third on the final priority list. This implies that stakeholders in Nepal believed that knowing the national representative estimates of suicide rates in various groups and factors associated with it was an essential pre-requisite to developing and evaluating the most effective interventions.
A significant proportion of people who complete, attempt or consider suicide do not seek help from family members and health care facilities . There may be many reasons for this, including beliefs about ineffective care, shame felt by the suicidal individuals and their family members  and stigma against suicide and mental health issues appear to prevent people from using the limited resources available . Studies have suggested that research is needed to clarify age and gender differences and the cultural and familial context of suicide bereavement, together with help seeking behaviours . Consistent with these findings, participants in our study emphasised exploring the barriers and enablers for help seeking among people considering suicide and their family members. Evidence on factors contributing to help seeking among these vulnerable group will guide the development of suicide prevention programs.
Examining the responses of the health and community service systems is an essential element of suicide prevention, as an ill-equipped health system will be unable to assess and manage people with suicidal thoughts or behaviours effectively . Several components of healthcare provision such as trained human resource, timely referral, universal screening of suicidal individual etc., have been found to be associated with reduced suicide ideation and to mitigate suicide deaths . Despite the Ministry of Health in Nepal having had a mental health policy since 1997, including a vision to integrate mental health services into general health services and a Multisectoral Action Plan for the Prevention of Non-Communicable Diseases (2014-2020) that included mental health, progress has been slow. The mental health Gap Action Programme (mhGAP), promoting community-based mental health programmes, has been shown to reduce suicidal tendencies and encouraged establishment of suicide hotlines in limited parts of the country [5, 22]. However, the wider impact of this programme is yet to be determined . Thus, studies assessing the status of such interventions and identification of the need for additional resources (human, equipment, and funding) at health facilities and police stations, appear warranted.
Those bereaved by suicide, whether family members or friends and colleagues, may experience a lasting impact of loss on their social life and on their physical and mental health . Published literature highlights significant areas of need regarding interventions to be conducted after a suicide, including; a) what interventions work (for groups, individuals, online, outreach, etc.), b) for whom should they be developed (e.g. children, adolescents, older adults, workplace, prison, and other populations), and c) what outcomes should be measured (e.g., stigma, mental health, suicidality etc.) . These recommendations were consistent with the findings of this study, with participants endorsing the need for research questions assessing the support needs of family members and ways to promote the implementations of appropriate interventions.
Limitations and strengths
To the best of our knowledge, this is the first Delphi study to collate research priorities for suicide prevention in Nepal. A key strength is that we included a wide range of stakeholders with different perspectives, including those with subjective expertise (patients and family members) and professional expertise (researchers, clinicians, advocates). This is in line with literature proposing that better quality and more broadly generalisable decisions are achieved through the process of achieving consensus in heterogenous group . Validity is also affected by the response rate  and retention rate, which in this study were very high. Employing face to face interviews where possible  and a quick turnaround time between questionnaires might have helped reduce attrition.
Limitations of the study include that expert who took part were not asked about their awareness of existing research in the area. Therefore, experts, particularly service users could have recommended research that had already been covered. Due to the Covid-19 pandemic, rounds 2 and 3 were conducted online rather than through group discussions which may have been preferable to encourage discussion and debate. However, our approach did provide participants with anonymity and confidentiality, which may have encouraged participation and engagement, and prevented dominance by influential individuals or group pressure that may otherwise have occurred .
Implications and recommendations
The findings from this study will help researchers, healthcare professionals, and policymakers prioritise funding strategies relating to suicide prevention. More importantly, studies that delve into the outcomes associated with exploring ways to improve suicide reporting, as well as assessing the burden and factors associated with suicide have much to offer in increasing the understanding of this area.