Implementation of Zero Suicide in a Country with Restrictive Suicide Laws

Suicide is a major global public health concern, claiming over 720,000 lives annually. Nearly 75% of suicides occur in low- and middle-income countries (LMICs), where data systems and prevention resources are limited. In some LMICs, including Nigeria, suicide attempts remain criminalized. Nigeria’s suicide rate (17.3 per 100,000) exceeds African and global averages, and stigma further hinders care. Although Nigeria adopted a National Suicide Prevention Strategic Framework (2023–2030) to train health workers and integrate prevention programs, implementation remains lacking. The American Foundation for Suicide Prevention prioritizes such contexts, emphasizing the need for effective strategies in under-resourced settings to reduce stigma, improve care, and address legal barriers.

Our project will co-create the Suicide prevention Adoption and Framework for Enhanced Response in healthcare (SAFER) approach for implementing a multifaceted, system-wide, evidence-based suicide prevention initiative, the Zero Suicide (ZS) Model, in Nigeria that can provide a model for implementation of suicide prevention interventions in other countries where suicide is also illegal. ZS has proven to reduce suicide attempts and deaths by up to 80% globally. Implemented in over 20 countries and hundreds of U.S. health systems, ZS integrates four core clinical steps: risk screening, engagement in care, targeted interventions, and continuity of specialty care.

In Aim 1, we will examine provider attitudes/stigma toward suicidality, and their perceptions of feasibility, acceptability and appropriateness of the ZS framework for suicide prevention in Nigeria, including Organizational Readiness for Implementing Change. We will conduct the study in 12 hospitals in the Nigeria Implementation Science Alliance Model Innovation and Research Centers (NISA-MIRCs) hospitals across Nigeria’s six geopolitical zones, ensuring findings are nationally representative and applicable throughout the country. We will use a mixed-methods approach (720 provider surveys and interviews with health managers of the 12 NISA-MIRCs hospitals, 6 key informant interviews, and three focus group discussions with 30 healthcare workers across the six zones of Nigeria).

Aim 2. Using information collected in Aim 1, from implementation of ZS elsewhere, and from other Nigerian implementation efforts (e.g., cervical cancer), co-create the SAFER implementation intervention for implementing ZS in Nigeria, a country where suicide is illegal, using implementation mapping, with of academic, public health, clinical and government partners including patients/advocates and people with lived experience. Results from our interviews in Aim 1 will inform what needs to be done, who will do it, and how to make it work well in the Nigerian setting.

Assessing the feasibility of established, evidence-based interventions in LMIC settings helps determine which can be implemented and where new ones may be needed. The successful completion of the project may help save thousands of lives through widespread national adoption aligned with Nigeria’s new suicide prevention policy. This study will also guide broader suicide prevention initiatives in other LMICs, particularly in countries where suicide attempts remain criminalized. It will establish the PI’s career as an independent clinical scientist and lay the foundation for a future implementation trial of the proposed SAFER implementation approach, enabling further contributions to suicide research.