{"paper_id":"4cfa530d-4749-4698-9f1e-b392f538890f","body_text":"Process Evaluation of the Follow-Up Care System for Suicide Attempt in Iran: A Mixed- Method Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Process Evaluation of the Follow-Up Care System for Suicide Attempt in Iran: A Mixed- Method Study Fatemeh Shirzad, Forouzan Fahim, Morteza Naserbakht, Ahmad Hajebi, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4886363/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Dec, 2025 Read the published version in BMC Psychiatry → Version 1 posted 4 You are reading this latest preprint version Abstract Background Despite ongoing efforts to provide hospital and post-discharge care for suicide attempters in Iran, national suicide rates continue to exhibit a concerning upward trend. This study employs the MRC framework, a comprehensive evaluation tool, to conduct a process evaluation of Iran's suicide follow-up care system in Shahriar city. Methods We examined fidelity, dosage, reach, impact, and contextual determinants of the program. An explanatory sequential design was employed. Data from 992 suicide attempt cases collected between April and September 2023. Semi-structured interviews were conducted with 19 mental health workers, 2 mental health experts, 16 hospital staff members, and 8 individuals with who have suicide attempts. Results Findings indicated that of the 992 individuals referred for receive services, only a small number (n = 15) engaged with designated health centers, with a completion rate of a mere 3 individuals, suggesting significant limitations in program reach. Qualitative analysis revealed nine thematic domains aligned with the MRC framework: infrastructure, information gaps, and human resource challenges within implementation mechanisms; participant experiences, and acceptability, related to impact mechanisms; and socioeconomic factors, stigma, organizational barriers, and access to means restriction as contextual components. Conclusion This study in Iran offers a unique contribution by employing a comprehensive framework to systematically evaluate the national suicide follow-up system, its role within broader prevention efforts, and strategies to enhance program effectiveness. The Follow-Up Care System for Suicide Attempt provides a crucial resource for Shahriar residents at risk of suicide, who often grapple with compounded challenges stemming from socioeconomic factors. Our findings underscore critical operational and contextual barriers, providing essential evidence for policymakers to address. While demonstrating initial promise, the program requires substantial improvements. To maximize its impact, we need to strengthen program implementation, allocate sufficient resources, build community partnerships, and advocate for policy changes that address the root causes of these issues. Process Evaluation Suicide Iran Figures Figure 1 Figure 2 Figure 3 Background A 40-year-old male patient was transported to a Shahriar city, Tehran province hospital by emergency medical services following a suicide attempt by hanging. He was discharged the same day but subsequently died from injuries sustained in a fall three days later. Such cases underscore the importance of one critical element: implementing effective follow-up systems to ensure the safety and well-being of those who have attempted suicide.( 1 ) Given the elevated risk of subsequent suicide attempts, timely intervention is paramount. ( 2 ) However, the implementation of effective follow-up support remains a significant challenge. ( 3 ) To address this critical gap, Iran implemented a nationwide suicide prevention program within its primary health care system in 2010. A core component of this initiative involves providing structured follow-up care for individuals who have attempted suicide, both during hospitalization and post-discharge. ( 4 ) A pilot phase involving intensive post-discharge follow-up for suicide attempt survivors was implemented across four Iranian provinces beginning in early 2017. This model was subsequently expanded nationwide. ( 5 ) The program developers reported that the evaluation revealed a significantly lower rate of suicide re-attempts among individuals who fully cooperated with the intervention. This cooperation included answering phone calls and agreeing to in-person visits for four sessions of brief psychological intervention after being referred from the hospital to the Health network. These findings suggest that the program may be effective in reducing suicide re-attempts. However, recent statistics indicate an overall increase in the rate of suicides. For instance, in 2019, there were 5,143 recorded suicides in Iran, representing an 11% increase compared to the 4,625 suicides recorded in 2017.( 6 ) Suicide rates have shown a concerning upward trend, necessitating a critical evaluation of existing prevention programs. This concern, coupled with the absence of any process evaluation of the program, motivated us to conduct this research. The current study aims to address the critical gap in knowledge regarding the implementation of this program through a rigorous process evaluation. Previous research has primarily focused on outcomes, with limited attention paid to how programs are actually implemented. A review of 42 papers from six multilevel suicide prevention trials identified a significant dearth of process evaluation. Only four studies included any process evaluation component, and a mere two provided comprehensive details on methodology and results. ( 7 ) This gap is particularly pronounced in the Iranian context, where the overwhelming majority of studies have focused exclusively on program outcomes, with a complete absence of process evaluation.( 8 ) Process evaluation is a systematic method for assessing how well a program is delivered compared to its planned design. It provides valuable insights into program implementation, mechanisms of change, and contextual factors influencing outcomes.( 9 ) To structure our evaluation, we employ the Medical Research Council (MRC) framework, a robust approach for assessing the complexity of health interventions.( 10 ) Based on this framework, our study focuses on three key objectives: Objective 1: Evaluate program implementation by assessing dose, reach, and fidelity. Objective 2: Explore mechanisms of change to understand how the program generates intended effects. Objective 3: Identify contextual factors influencing both program implementation and outcomes. Method Study design This study, embedded within a larger action research project, employed a mixed-methods explanatory sequential design to evaluate the Follow-Up Care System for Attempted Suicide. Adopting MRC Framework, the study focused on assessing the system's implementation fidelity, dose, and reach, understanding its mechanisms of impact on patients, and examining the influence of contextual factors( 10 ) One challenge, as underscored in the full guidance document of MRC, is the absence of a consensus on the optimal division of evaluation into key subcomponents. To address this, we identified seven components based on the MRC framework and previous studies ( Table 1 ).( 11 , 12 ) Table 1 process evaluation components, research questions and data sources Themes for process evaluation Components Questions Data source Implementation Reach How many people attempting suicide are registered in the follow-up system? Routine monitoring data, Registration Form, Health Record System Does Delivered How many sessions of brief psychological intervention were actually delivered to participants? Routine monitoring data, Registration Form, Health Record System, Fidelity To what extent did the follow-up system adhere to the original design? Were there any deviations in how follow-up system was delivered (e.g., content of sessions, training of providers? Checklist, Implementer interview, Document Review Focus Groups site visits Mechanisms of impact Acceptability • To what extant participants were satisfied with follow-up system? Focus Groups Implementer interview Dose received To what extent did they participate in the intervention sessions and utilize the resources provided? participant interviews Context Context How and in what ways do contextual factors affect the implementation of follow-up system? Implementer interview Settings and participants This study centered on individuals with a history of suicide attempt and healthcare providers situated within the context of general hospitals and health centers in Shahriar County, Tehran Province. Characterized by a population of 950,000 experiencing rapid growth and significant inward migration, Shahriar County exhibits a prevalence of deprived and marginalized communities, as well as a range of associated socio-economic challenges.( 13 ) The study comprised nineteen mental health workers (MHW), two mental health experts (MHE), sixteen hospital staff members, and eight individuals who had previously attempted suicide. Data pertaining to 992 individuals who had attempted suicide between April and September 2023 were incorporated into the study. These cases were referred to the health network by general hospitals and emergency medical services(EMS).( 14 ) Follow-Up Care System for Suicide Attempt in Iran The third strategic objective of Iran's comprehensive suicide prevention program aims to enhance the quantity and quality of services provided to individuals at risk of or having attempted suicide. Post-suicide attempt care is primarily managed within the primary care system, facilitated through collaborative efforts between hospitals and health centers (Fig. 1 ). Upon presentation to the emergency department, individuals receive diagnostic and therapeutic interventions. When clinically indicated, psychiatric consultation is arranged. Subsequent to a comprehensive evaluation, decisions regarding hospitalization or discharge, accompanied by a psychiatrist-prescribed medication plan, are made. Hospital social workers are mandated to conduct at least one intervention session with each patient and are responsible for informing them about subsequent care at the health center. Ongoing support is provided by hospital social workers until a referral to the health center is established. A weekly list of discharged suicide attempters is transmitted to the health network. Mental health experts are obligated to contact these individuals and refer them to the nearest health center. General practitioners at the health center initiate care and subsequently refer patients for psychological interventions delivered by MHWs. The program strives to ensure that all individuals who have attempted suicide and have been referred to mental health experts receive at least one brief psychological intervention session. The proportion of individuals who have attempted suicide, referred from hospitals to the health network, and subsequently receiving at least one brief psychological intervention serves as the evaluation indicator for this objective. To bolster the knowledge and skills of mental health professionals within the PHC system, a comprehensive psychological intervention package for suicide prevention has been developed. Based on \"Brief Intervention in Suicide Attempts: A Handbook for Clinicians\" (2nd Edition) by Dr. Angela Gaynes Myer and Dr. Konrad Michael, this package outlines a short-term psychological intervention and follow-up strategy comprising 3–4 sessions over 2–4 weeks. Core components of the intervention include conducting a narrative interview, reviewing the interview findings, identifying patterns leading to the suicide crisis, and re-exposure therapy. . Procedure and Data Collection To facilitate the development and implementation of the follow-up system, robust partnerships with key stakeholders were cultivated. Collaborative meetings with the university's health department vice-chancellor and the head of Shahriar city's health and treatment network secured essential support for the evaluation. These relationships proved instrumental in understanding the intervention's dynamics and addressing implementation challenges. The evaluation team comprised a multidisciplinary group of four psychiatrists, two psychologists, a community mental health specialist, a methodologist, and two social medicine experts. This diverse expertise enabled comprehensive data collection and analysis, guided by a principal investigator for effective coordination. To establish a clear framework for the evaluation, the follow-up system was meticulously described, including its underlying causal assumptions. Given the initial lack of clarity surrounding the intervention, a logic model was developed in collaboration with intervention developers. This model elucidated the intervention's components and anticipated outcomes, informing subsequent research questions and methodologies. Core research questions were formulated based on the intervention's causal assumptions and stakeholder input. This focused approach prioritized critical uncertainties and meaningful outcomes for the evaluation. Data collection employed a mixed-methods approach, incorporating routine monitoring data, registration forms, implementer self-reports and interviews, document reviews, focus groups, site visits, participant interviews, and stakeholder interviews. This triangulation of data enhanced the study's validity and reliability in assessing the follow-up program. ( 15 ) Data collection was conducted in two phases: quantitative and qualitative. Quantitative Data Quantitative data encompassed the number of health center visits by suicide attempters, intervention session frequency following phone calls, and implementation process details of the follow-up system. These data were extracted from general hospital registration forms, the \"SINA\" Health Record System's routine monitoring data, and the National Registration System of Suicide Behaviors. The National Suicidal Behavior Registration System captures comprehensive data on suicidal behaviors from hospital-submitted registration forms, informing suicide prevention strategies. The \"SINA\" health record system documents individuals accessing mental health services, ensuring care continuity. Qualitative Data Following the completion of the quantitative phase, qualitative data collection commenced. This phase involved interviews, focus groups, self-reports, document reviews, and site visits. Participants for semi-structured interviews and focus groups were selected through purposive sampling. To prioritize participant comfort and privacy, interviews were conducted at either the participants' workplaces or the health network. All interviews were facilitated by trained researchers proficient in qualitative interviewing techniques and were conducted in Persian. A standardized semi-structured interview guide was employed.( 16 ) A total of six focus group discussions were conducted: three involving 16 participants from three different hospitals and three comprising MHEs and MHW. Participant diversity was prioritized to enrich the data collected. ( 17 ) To gain a deeper understanding of the system's practical implementation, site visits were conducted at comprehensive health service centers. Observations and informal conversations with staff during these visits offered valuable insights into daily operations and the challenges encountered by healthcare providers.( 18 ) Additionally, self-reports from MHWs over the past six months were analyzed. Document review encompassed the national suicide prevention program (including resource review, stakeholder analysis, implementation background, goals, strategies, and operational plan), guidelines for providing suicide prevention services within the healthcare system, protocols for short-term psychological intervention and post-discharge follow-up for suicide attempters, and other educational materials intended for mental health professionals. Analysis Quantitative data on program reach and dose, were analyzed using descriptive statistics.( 19 ) Reach and dose were assessed by examining the number of delivered psychological intervention sessions and the proportion of individuals receiving at least one session. To analyze the qualitative data, we employed the Framework Method, a systematic approach commonly used in multidisciplinary healthcare research. This method involved a seven-step process to identify and interpret key themes within the data.. ( 20 ) Initially, the interviews were transcribed to ensure a comprehensive understanding of the data. Subsequently, familiarization with the interviews was conducted by reviewing both the audio recordings and transcripts. This step allowed for immersion in the data and facilitated the identification of key themes and patterns. Re-listening to the recordings provided further insights into the interview context. Next, systematic coding was undertaken. Selected transcripts were meticulously reviewed, and codes were applied to capture significant aspects of the data. Although the MRC framework guided our approach, our coding was not purely deductive, incorporating elements of \"open coding\" to allow for the emergence of new themes. Following the coding process, a working analytical framework was developed. Researchers convened to compare and consolidate the codes applied to the transcripts, thereby forming a cohesive framework. This analytical framework was then applied to subsequent transcripts through the process of indexing, ensuring consistency and depth in the analysis. MAXQDA was utilized to streamline this process, enhancing both efficiency and organization. The data was then charted into a framework matrix, with a spreadsheet summarizing the data by category from each transcript. This matrix incorporated illustrative quotations to facilitate deeper analysis and interpretation. Subsequently, the data was classified within the MRC framework. The final step involved data interpretation, guided by early impressions and ideas noted throughout the analysis. Characteristics and differences within the data were identified, leading to the generation of findings that extended beyond mere description. This stage involved exploring themes, generating typologies, and examining theoretical concepts to provide comprehensive insights into the implementation process and its impact. To ensure the rigor of our data analysis, we adhered to the criteria for trustworthiness outlined by Guba and Lincoln. ( 21 ) RESULTS The results are presented in two sections: quantitative and qualitative. Prior to initiating the evaluation, we developed the program's logic model, as illustrated in Fig. 2 . Quantitative Results Access: A total of 992 individuals who attempted suicide were referred from general hospitals to health network between April and September 2023. Table 2 presents the demographic characteristics of these individuals. Table 2 Demographic characteristics Demographic Variables 992 Age Mean ± SD 29·9 ± 12·04 Min.-Max. (11–81) Sex Male 391 (39·41%) female 589 (59·37%) Unknown 12 (1·2%) Marital Status Single 211 (21·27%) Married 255 (25·7%) Divorced 27 (2·72%) Unknown 499 (50·3%) Of the 992 individuals referred, contact was established with 903. Among these, 525 answered the phone directly. In cases where contact was unsuccessful, reasons included incorrect phone numbers, unanswered calls, or switched-off phones. Out of the 525 who answered, 178 were the individuals who attempted suicide, while 347 were other respondents. A total of 15 individuals accessed and completed at least one brief psychological intervention session offered at health centers, demonstrating limited program reach. Further details and information are available in Fig. 3 . Delivered Dose: The intervention protocol included 3 to 4 sessions delivered over a 2 to 4-week period for each participant. While all 15 participants began the intervention, attendance declined over time. Eight participants attended the second session, four attended the third, and only three completed all four sessions Qualitative Results: Through inductive analysis of interview data, nine categories emerged, which were subsequently aligned with the MRC framework themes. (Table 3 ) Table 3 Categories resulting from qualitative analysis Category MRC Theme Infrastructure Implementation Information gap Human resource Participant experiences Mechanisms of impact Program acceptability Socioeconomic Factors Context Stigma and lack of awareness Organizational issues Easy access to means of suicide Reach Multiple factors contributed to low program accessibility, as revealed through interviews and observations. A primary challenge was ineffective communication between general hospitals and health centers, resulting in information gaps. Furthermore, initial contact with suicidal individuals often occurs through Emergency Medical Services (EMS), who, due to urgent medical priorities, are unable to gather comprehensive patient information, hindering subsequent follow-up. “When EMS brings in an emergency patient, they might not even give us a name and bring them in as anonymous patients. The emergency department records any information the patient provides to them, and most cases we handle are usually like this.\" (Hospital nurse) After the individual is taken to the hospital emergency department via EMS, there is another opportunity during admission to collect their information. However, even at this stage, there are deficiencies, and the information sent to health centers often lacks demographic variables such as marital status, employment status, educational status, and even the national ID and phone number of the individual. The form provided to hospitals to send individuals' information to the health network is comprehensive but is not fully completed. Additionally, a critical oversight exists in differentiating between accidental and intentional poisonings. Currently, the reason for poisoning is documented without clarifying intent, hindering accurate data analysis and targeted interventions. While hospital staff informally exclude cases of accidental poisoning and alcohol consumption, a standardized, comprehensive system for this distinction is absent. \"Some cases are removed from the list based on the doctor's opinion. This is because the individual says they did not intend to commit suicide; they simply took more pills by mistake. Since the EMS service does not take a detailed history and labels everyone as a suicide attempt.\" (Hospital staff) Following the transmission of data to the health network, as outlined in the protocol, MHWs encounter significant challenges at the health center level. The absence of complete patient information severely hinders their ability to reach individuals for follow-up care. “Even cases that have phone numbers may be incorrect, unavailable, or unreachable, or the number may even belong to a neighbor who contacted the emergency services.\" (MHW) \"Suicide cases are reported from hospitals to the network, and the list that comes from the emergency services almost has nothing except the name, address, age\" (MHE) Compounding this issue, MHWs report the presence of duplicate and conflicting patient records across various lists. Discrepancies in patient age, details, and even overlapping names in both emergency and hospital lists impede accurate data management. These challenges, combined with infrastructural limitations such as shared consultation rooms for MHWs and nutritionists, further restrict patient accessibility and continuity of care. \"Our center only has one phone line. Firstly, in the mornings, we cannot make calls and have to wait until noon to call people, and since we only have one line, making calls becomes difficult. The line gets busy.\" (MHW) \"Not having a phone line significantly affects us. It makes calling difficult, and sometimes some colleagues have to use their personal phones to make calls, which itself causes problems.\" (MHW) Notably, inconsistent approaches to initial contact were observed among MHWs. While some practitioners adopted a sensitive, indirect approach, others used direct language disclosing the reason for the call. These varying methodologies highlight the need for standardized guidelines for initial contact and obtaining consent. Some notes from MHWs following their calls to participants are presented in Supplementary 1. Fidelity Interview results reveal a significant lack of program fidelity, particularly within the hospital sector. Psychological care is notably underemphasized, often overshadowed by a focus on physical health. This disparity is alarmingly evident in cases involving high-lethality suicide attempts, where patients without physical injuries may be discharged due to the absence of psychiatric and psychological professionals. \"If we see that the individual might attempt suicide after being discharged, the only thing we can really do is refer them to the health network so they can use mental health services.\" (Hospital staff) The scarcity of psychiatric beds in Shahriar’s public hospitals necessitates referrals to specialized psychiatric facilities, further underscoring the system’s limitations. Moreover, a shortage of social workers, as reported by hospital staff, exacerbates the issue. \"We need to hire a nurse specifically for suicide cases. For example, we have someone here who follows up on hypertension cases. Suicide is much more complicated because, in hypertension, the person acknowledges they have a problem and listens to whatever you say.\" (Hospital nurse) \"We don't have a poisoning department, nor do we have a psychiatrist or psychologist. Once their initial treatment is done, they are sent to a psychiatric hospital. If they personally consent, they are discharged. Hanging cases, once they are physically stable, are coordinated to be transferred.\" (Hospital nurse) \"For example, I referred a case to Iran Psychiatric Hospital, and the doctor wrote that the person has a problem and needs hospitalization, but they don't have any available beds.\" (Hospital nurse) \"I am just a social worker, and I am not always in the hospital. I think there should be coverage by shifts in all hospitals. We don't have a social worker in all shifts; practically, during holidays and night shifts, the nursing supervisor takes on the role of the social worker, and well, many things cannot be thoroughly examined from other aspects.\" (Hospital social worker) Despite protocol mandates for weekly reporting of suicide cases to the health network, mental health experts indicate that this information is currently submitted on a monthly basis. Additionally, healthcare centers demonstrate substantial deviations from intervention protocols, with sessions and materials frequently failing to adhere to guidelines. \"The protocol states that contact should be made with MHE at the health network, and then those who have expressed readiness should be referred to us for MHWs. But currently, they just give us the names and we have to make the calls.\" (MHW) \"Many times, we cannot even perform the tasks requested of us. For example, we have to give tasks to clients. Sometimes they are illiterate, sometimes they are children, and these tasks are too heavy for them, and they cannot understand and do them.\" (MHW) Mechanisms of Impact Acceptance Opinions among MHWs diverge regarding the efficacy of follow-up care for individuals who have attempted suicide. Some professionals assert that delays in administrative processes often hinder the effectiveness of these follow-ups, leading to minimal improvement in the individual's psychological state. \"Generally, the follow-up of individuals who have attempted suicide in any way must be done, but these phone follow-ups, which, due to administrative delays, occur long after the suicide, are practically useless.\" (MHW) MHWs highlighted the substantial gap between a suicide attempt and subsequent follow-up sessions as a significant challenge. \"The follow-up of suicide cases within 2 to 3 months after the attempt is not beneficial and effective because the individual's mental and emotional conditions change over time, and they may not feel the need for counseling or treatment.\" (MHW) Some interviewees questioned the utility of these follow-ups, particularly for individuals grappling with financial or familial crises. \"If you ask me, it's pointless, especially in this region, because when someone like Ms. X comes in, who doesn't even have money to see a doctor or eat, how does psychological intervention and self-care help this patient when they are still struggling with basic needs? Sometimes I really don't know what to say when they tell me they don't have anything to eat, and I suggest counseling, but it doesn't help.\" (MHW) \"During my 10 months of service so far, only 3 people from the lists have come for consultation, and most of them are in high-stress families or have addicted caretakers, facing difficult financial and life conditions. They thought we could help them financially, but after realizing that's not the case, they stopped coming.\" (MHW) Additionally, the high turnover rate among MHWs was identified as a barrier to effective long-term care. “Our MHWs are constantly relocating. Psychology is about building relationships. You settle into a center, establish connections with clients, and then after a few months, they send you to another center, and you lose touch with your previous clients.\" (MHW) Despite these limitations, some interviewees acknowledged the potential benefits of follow-ups, such as increased awareness of available resources, family education, and emotional support. \"It seems beneficial to me that we can help even one person and raise awareness. Providing education to families is valuable. I believe I have been able to establish connections with everyone who attempted and raise their awareness.\" (MHW) \"One of the experiences I have from follow-ups is about a teenage boy who had attempted suicide multiple times. He came with his father, and with the interventions we provided, he found motivation to continue his education and also decided to work in a store due to financial difficulties.\" (MHW) Received Dose While service providers expressed mixed views, participants overwhelmingly reported positive experiences with the program. Despite the limited sample size, this group consistently described significant improvements in stress management and a decrease in suicidal ideation. \"I attended several sessions, and thankfully, it was good. Talking to the therapist calmed me down. They also taught me about parenting. Then, they talked to my husband as well. They referred me to a psychiatrist, and now I am taking medication.\" (Service user) \"These sessions helped me know what to do when suicidal thoughts came to me. Previously, when I didn't know these techniques, I used to get very upset.\" (Service user) \"The psychologist puts in a lot of effort, but there are some bigger problems that I have that they can't solve. If these problems are solved, my situation would be much better.\" (Service user) However, participants commonly cited EMS and hospital emergency department, as areas requiring improvement. \"It wasn't very helpful when EMS arrived and asked me why I attempted suicide. Then, when I went to the hospital, even though my mental state wasn't good, they discharged me.\" (Service user) Also participants frequently identified gender dynamics and domestic violence as significant barriers to accessing healthcare services, highlighting these issues as particularly problematic for women. \"After someone from the health center called, asked about my well-being, and suggested I attend a counseling session, I felt happy and realized I wasn't alone” (Service user) \"Most of the time, I go to the psychologist in secret and try not to let my husband know because he is against it. But these sessions do help me.\" (Service user) Context The implementation and effectiveness of the suicide prevention program were significantly influenced by contextual factors. Lack of awareness and prevailing stigma emerged as key barriers, with individuals often hesitant to recognize warning signs or seek help due to fear of judgment. Families also contributed to the challenge by denying suicide attempts or withholding relevant information. \"Families usually do not mention suicide due to its taboo nature. There have been cases where we have contacted families for follow-up and they have denied it, saying that the person took the pills accidentally and even asking us not to register it as a suicide attempt.\" (MHW) “ This electronic registration also causes problems for us. Families come and say why we registered it in the system and they think it will cause problems for them . \" (MHW) Moreover, easy access to suicide methods was identified as a concerning factor. \"Last week, they brought in a 15-year-old girl who had taken rice pills purchased from a herbal shop. There needs to be more supervision on these things.\"(Hospital staff) Financial constraints, including insurance limitations, were reported as obstacles to accessing necessary treatment and follow-up care. \"Cost is a major issue for us. Most of these individuals don't have insurance, so when they need counseling, they have to pay for it themselves. Not having a mental health unit is very challenging for us.\" (Hospital nurse) \"Some who don't have money and get hospitalized until they regain consciousness escape from the hospital, and then it's impossible to continue their follow-up care.\" (Hospital staff) “We had a person with suicidal thoughts, but they didn't have money to go to a psychiatrist.'\" (MHW) \"The main reason for suicide attempts in the area is poverty and addiction. As long as we don't have financial support, people won't come to us or trust us. There was someone who attended all sessions, and we helped them, but out of 10 people, maybe 1 person comes, and even that is uncertain... I followed up with one of the clients five times before they came.\" (MHW) Cultural factors, particularly those related to gender, were highlighted as impediments to program implementation, with MHWss emphasizing the impact of gender-based issues. “Sometimes when I call a woman and her husband or brother answers, they get angry and ask why I called and where I got the number.\" (Male MHW) \"Many times, a woman who has attempted suicide has also been a victim of domestic violence, and her husband does not allow her to come to the sessions, which makes it very challenging for us to intervene in such cases. Even if we contact the police or social services, it usually doesn't yield much result.\" (MHW) Organizational changes also hindered program implementation and evaluation. For instance, the EMS department discontinued providing suicide statistics from September 2023 onward, impacting data collection and analysis. \"Since the emergency department became independent, we haven't received suicide statistics for months now. This doesn't mean that suicides have decreased; it's because the emergency department hasn't provided us with suicide statistics for several months now.\" (MHE) DISCUSSION Rigorous evaluation of suicide prevention programs is essential for optimizing their efficacy and enhancing mental health outcomes. This study undertook a process evaluation of a post-suicide attempt follow-up system in Iran, examining implementation fidelity, mechanisms of impact, and contextual determinants. Findings revealed significant challenges in program delivery. Quantitative data indicated suboptimal stakeholder access, low service utilization, and poor adherence to program protocols. The qualitative section explored the underlying reasons for these challenges, which will be discussed in detail. A meta-analysis of over 500 quantitative studies underscores the critical role of implementation fidelity in determining the outcomes of promotion and prevention programs.( 22 ) Achieving adequate reach within the target population is a fundamental aspect of program implementation. Consequently, calculating participation rates is essential for assessing the potential impact of interventions. ( 23 ) By meticulously examining reach and participation, programs can refine their strategies to optimize engagement and effectiveness.( 24 ) Moreover, tailoring program components to the specific characteristics and needs of diverse demographic groups is imperative for maximizing inclusivity and participation.( 25 ) The evaluation uncovered substantial gaps in program fidelity across both hospital and health centers. Hospitals exhibited a critical dearth of essential resources, including the absence of on-call psychiatrists, insufficient social workers, and a complete lack of psychiatric inpatient beds. These deficiencies represent a stark deviation from the program's outlined provisions. Despite a Ministry of Health mandate allocating 10% of hospital beds to psychiatric care, Shahriar city currently lacks any psychiatric inpatient facilities. In primary care centers, program implementation also fell short of expectations. Notably, the program's design disproportionately burdens primary care facilities with follow-up responsibilities, contrasting with the hospital-centric approach common in other countries. ( 26 – 29 ) The identified systemic deficiencies culminate in substantial delays between suicide attempts and the initiation of follow-up care, often extending to as much as three months. Given the critical importance of timely intervention in suicide prevention, these delays significantly compromise the program's effectiveness. This protracted response stands in stark contrast to evidence-based guidelines from programs such as the National Suicide Prevention Lifeline in the USA and the LifeSpan program in Australia, which emphasize the need for follow-up within 72 hours of discharge. ( 28 , 30 ) A study revealed that only 30.9% of individuals discharged from U.S. hospitals following hospitalization for suicidal ideation, attempts, or self-harm initiated outpatient mental health treatment within a week of discharge. ( 31 ) The program's efficacy has been questioned by certain service providers, raising concerns regarding its overall acceptability. Conversely, proponents have emphasized the potential advantages of follow-up services in terms of emotional support and awareness enhancement. Also, interviews with survivors of suicide attempts indicated that the intervention contributed to improved coping mechanisms and a reduction in suicidal ideation. It is crucial to consider that negative feedback from MHWs may not necessarily reflect shortcomings of the program itself but rather implementation challenges. For example, high turnover rates among MHWs can impede the delivery of optimal services, particularly in mental health contexts where establishing a strong therapeutic alliance is fundamental to effective intervention. .( 32 ) The experiences of individuals facing EMC have not always been favorable. Multiple studies emphasize the importance of establishing a patient-provider relationship and understanding the psychological state of patients, including those with suicidal thoughts( 33 ) To improve suicide intervention skills among EMS providers, emphasis should be placed on their attitudes towards suicide prevention, stress management skills, ongoing training in suicide intervention techniques, active listening skills, empathetic communication, and compassionate attention. ( 34 , 35 ) The study underscored the profound influence of contextual factors, including socioeconomic conditions, gender dynamics, infrastructural limitations, accessibility to suicide-related means, and systemic barriers, on program implementation and efficacy. These findings underscore the critical role of addressing social determinants of health and tailoring interventions to the specific needs of vulnerable populations. A study on financial support for regional suicide prevention programs in Japan found a positive correlation between increased budgetary allocations and decreased suicide rates ( 36 ) These findings suggest that investing in suicide prevention programs can effectively reduce rates, highlighting the importance of alleviating financial burdens as part of the strategy. ( 37 ) Our findings demonstrate that cultural norms and gender roles significantly influence help-seeking behaviors and access to mental healthcare in contexts such as Iran. This underscores the imperative for culturally tailored interventions that directly address these barriers. Also Stigma emerged as a pervasive challenge hindering the effective implementation of suicide prevention programs. Notably, stigma impacts both individuals who have attempted suicide and their surrounding communities. Survivors of suicide loss often endure shame, blame, and societal judgment, fostering isolation and hindering the grieving process. ( 38 ) On the other hand, the fear of social disapproval and negative consequences associated with suicide attempts deter individuals from seeking help, potentially exacerbating their mental health crisis.. ( 39 , 40 ) Our study exemplifies the potential for unintended consequences arising from organizational changes within healthcare systems. Specifically, alterations to emergency department reporting procedures have adversely impacted the availability of critical data for program monitoring and evaluation. Given the established importance of robust data collection for effective suicide prevention these changes pose a significant challenge. ( 41 ) Iran's PHC system mandates the oversight of health centers and public hospitals by the Health Network. However, the Health Network in Shahriar County currently lacks the authority to effectively influence public hospitals, creating a significant governance gap that hinders coordinated service delivery. Our recommendation for following up on suicide attempts is to conduct these follow-ups within the hospital itself. Findings indicate that hospital emergency departments can serve as pivotal focal points for suicide intervention therapies. ( 42 ) Results of a study in England showed that continuity of care by the same clinician who saw the patient in the hospital can significantly increase the likelihood of the patient attending subsequent appointments.( 43 ) This underscores that even the specific healthcare provider is important, let alone changes in the location. When immediate in-hospital follow-up is not possible, better coordination with the health network is essential. This can be done through a unified referral system that registers hospitalized individuals daily, allowing healthcare providers to initiate same-day contact. Discharging patients without collecting crucial information overlooks a vital opportunity for intervention. Enhanced information completeness and active follow-up calls would significantly improve program effectiveness. Research in Iran underscores that even telephone follow-ups for individuals with a history of suicide can markedly reduce suicidal ideation and significantly increase life satisfaction ( 44 ) Similarly, in other countries, interventions such as \"active contact and follow-up\" have been shown to reduce the risk of repeated suicide attempts among patients hospitalized in emergency departments. ( 45 , 46 ) In the second part, strengthening infrastructure is identified as a critical step toward enhancing the effectiveness of this program. This includes the provision of facilities such as dedicated rooms for mental health professionals and equipping health centers with telephone lines to facilitate easier access to individuals. Additionally, hospital compliance with mandates, such as allocating 10% of beds to psychiatric patients and designating specific psychiatric beds, is an essential measure. Moreover, bolstering human resources, including the presence of social workers, psychiatrists, and psychologists in hospitals, is fundamental for the successful implementation of these programs. Detailed guidelines for follow-up procedures, including protocols for conducting initial calls, can significantly increase access to critical care. Implementing mechanisms for gathering feedback from patients can also improve follow-up processes and overall care quality. Prioritizing comprehensive training for nurses and EMS staff is crucial in enhancing mental health care delivery. Promoting mental health education and augmenting budgets allocated to mental health services can significantly improve care processes. Furthermore, enhancing insurance coverage for mental health services and enforcing stringent regulations on access to means of suicide are additional measures that warrant consideration. Also our study suggests a need to expand current models of help-seeking behavior by incorporating cultural and structural factors. An intersectional lens reveals how discrimination and marginalization shape access to suicide prevention services, emphasizing the importance of addressing systemic inequalities in mental healthcare.( 47 ) This is the first study in Iran to present a structured and systematic approach using a comprehensive evaluation framework for assessing the suicide surveillance system and, more broadly, the national suicide prevention program. Through this evaluation, we have provided valuable evidence for policymakers to review and address foundational and operational barriers to the program's implementation. One limitation of this study is its reliance on data from a short follow-up period after suicide attempts. While this provides a significant dataset, it may limit the generalizability of the findings. Additionally, the small sample size of participant experiences, due to accessibility constraints, may overrepresent individuals with positive outcomes. Furthermore, the absence of outcome evaluation restricts the depth of analysis. Future research should include outcome assessments and replicate the study nationally to enhance the generalizability of results. Also, Exploring innovative interventions, such as digital tools and remote healthcare services, alongside traditional approaches, should be prioritized. Conclusions The process evaluation provided valuable insights into the strengths and weaknesses of the suicide prevention program and highlighted areas for improvement. Importantly, we cannot definitively state whether the program is good or not. If a program is not properly implemented, we cannot determine its effectiveness. Negative outcomes may be due to poor implementation rather than the program itself. The program offers a crucial resource for Shahriar residents at risk of suicide, who often grapple with compounded challenges stemming from socioeconomic factors. To maximize its impact, we need to strengthen program implementation, allocate sufficient resources, build community partnerships, and advocate for policy changes that address the root causes of these issues. Abbreviations Mental health workers MHW Mental health experts MHE Primary health care PHC and emergency medical services EMS Declarations Human Ethics and Consent to Participate declaration Full explanations were given to the participants about the research and their consent was obtained to participate in the study.This study was approved by the Ethics Committee of Iran University of Medical Sciences, reference number IR.IUMS.REC.1403.311 Consent for publication Informed consent was obtained from all participants prior to their inclusion in the study. Competing interests We declare no competing interests. Funding This research was funded by HSR committee, grant number 1403-1-8-27910. The funder had no role in the design of the study; in the collection, analysis, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results. Author Contribution FS, AK and MN were the designers of this study, and FS, along with AK, was responsible for managing and executing the project. AK, MN, and PA were involved in the quantitative data analysis. AK, PA, and SZ conducted and analyzed interviews and focus group sessions, cleaned and validated the data. MN and FF were responsible for inter-departmental coordination. FF, FS, VSH, AH, and MN critically reviewed and finalized the manuscript. FS and MN had access to the data and verified it. FF, FS, MN, AH, and VS supervised the project. SZ PA, and AK prepared the first draft. All authors reviewed and approved the final version, had full access to all data, and had the ultimate responsibility for the decision to submit for publication. Acknowledgement We would like to express our sincere gratitude to all those who participated in this study and contributed to its successful completion. We are particularly grateful to the vice-chancellor of the university's health department for his support in conducting this evaluation. We also extend our thanks to the MHWs, healthcare workers, hospital staff members, and recipients who participated in the study. Their willingness to share their experiences and insights was invaluable. Data Availability Due to the sensitive nature of the data related to suicide, and in accordance with confidentiality regulations in Iran, we are unable to make this information publicly available. However, we are prepared to provide the data to referees and journal editors upon request. References Doupnik SK, Rudd B, Schmutte T, Worsley D, Bowden CF, McCarthy E, et al. Association of suicide prevention interventions with subsequent suicide attempts, linkage to follow-up care, and depression symptoms for acute care settings: a systematic review and meta-analysis. JAMA psychiatry. 2020;77(10):1021–30. Madsen T, Erlangsen A, Hjorthøj C, Nordentoft M. High suicide rates during psychiatric inpatient stay and shortly after discharge. Acta psychiatrica Scandinavica. 2020;142(5):355–65. O’Connor RC, Portzky G. Looking to the future: A synthesis of new developments and challenges in suicide research and prevention. Front Psychol. 2018;9:2139. Organization WH. National suicide prevention strategies: Progress, examples and indicators. 2018. Malakouti K, Nojomi M, Ghanbari B, Karimi H, Rasouli N, Fathi M, et al. Scaling up the Health System at Provincial Level to Conduct Telephone Follow-Up Program for Suicide Reattempters in West Azerbaijan, Iran, 2017–2018. J Suicide Prev. 2020;2(1):3–14. Souresrafil A, Mirzaei M, Rezaeian M. Suicidal behavior in Iran. Suicidal Behavior in Muslim Majority Countries: Epidemiology. Risk Factors, and Prevention: Springer; 2024. pp. 99–114. Zbukvic IC, Mok K, McGillivray L, Chen NA, Shand FL, Torok MH. Understanding the process of multilevel suicide prevention research trials. Eval Program Plan. 2020;82:101850. Doost Mohammadi F, Rezaeian M. The steps to develop a comprehensive suicide prevention strategy: A narrative review. J Rafsanjan Univ Med Sci. 2020;18(11):1155–82. Moore G, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, et al. Process evaluation of complex interventions: a summary of Medical Research Council guidance. Complex interventions in health: Routledge; 2015. pp. 222–31. Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W et al. Process evaluation of complex interventions: Medical Research Council guidance. BMJ. 2015;350. Liu H, Mohammed A, Shanthosh J, Laba T-L, Hackett ML, Peiris D, et al. Process evaluations of primary care interventions addressing chronic disease: a systematic review. BMJ open. 2019;9(8):e025127. Jong ST, Brown HE, Croxson CH, Wilkinson P, Corder KL, van Sluijs EM. GoActive: a protocol for the mixed methods process evaluation of a school-based physical activity promotion programme for 13–14year old adolescents. Trials. 2018;19:1–11. Mahdnejad H, Zanganeh A, Saeidirezvani N. Analysis spatial the overlap zoning of poverty and worn-out urban texture in the suburbs of Tehran. 2020. Worster A, Haines T. Advanced statistics: understanding medical record review (MRR) studies. Acad Emerg Med. 2004;11(2):187–92. Triangulation DS, editor. editor The use of triangulation in qualitative research. Oncol nurs forum; 2014. Guide I. Interview Guide. Merging Across Borders: People, Cultures and Politics. 2003:277. Rabiee F. Focus-group interview and data analysis. Proceedings of the nutrition society. 2004;63(4):655 – 60. Lawrenz F, Keiser N, Lavoie B. Evaluative site visits: A methodological review. Am J evaluation. 2003;24(3):341–52. Hickey G, McGilloway S, Furlong M, Leckey Y, Bywater T, Donnelly M. Understanding the implementation and effectiveness of a group-based early parenting intervention: a process evaluation protocol. BMC Health Serv Res. 2016;16:1–14. 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Riesch SK, Ngui EM, Ehlert C, Miller MK, Cronk CA, Leuthner S, et al. Community outreach and engagement strategies from the Wisconsin study center of the national children's study. Public Health Nurs. 2013;30(3):254–65. Welu TC. A follow-up program for suicide attempters: Evaluation of effectiveness. Suicide Life‐Threatening Behav. 1977;7(1):17–30. Catanach B, Betz ME, Tvrdy C, Skelding C, Brummett S, Allen MH. Implementing an emergency department telephone follow-up program for suicidal patients: successes and challenges. Joint Comm J Qual Patient Saf. 2019;45(11):725–32. Gould MS, Munfakh JL, Kleinman M, Lake AM. National suicide prevention lifeline: enhancing mental health care for suicidal individuals and other people in crisis. Suicide Life-Threatening Behav. 2012;42(1):22–35. Simpson SA, Goans C, Loh R, Ryall K, Middleton MC, Dalton A. Suicidal ideation is insensitive to suicide risk after emergency department discharge: Performance characteristics of the Columbia-Suicide Severity Rating Scale Screener. Acad Emerg Med. 2021;28(6):621–9. Shand F, Torok M, Cockayne N, Batterham PJ, Calear AL, Mackinnon A, et al. Protocol for a stepped-wedge, cluster randomized controlled trial of the LifeSpan suicide prevention trial in four communities in New South Wales, Australia. Trials. 2020;21:1–10. Schmutte T, Olfson M, Xie M, Marcus SC. Factors associated with 7-day follow-up outpatient mental healthcare in older adults hospitalized for suicidal ideation, suicide attempt, and self-harm. Am J Geriatric Psychiatry. 2022;30(4):478–91. Duncan BL, Miller SD, Wampold BE, Hubble MA. The heart and soul of change: Delivering what works in therapy. American Psychological Association; 2010. Hammarbäck S, Holmberg M, Wiklund Gustin L, Bremer A. Ambulance clinicians’ responsibility when encountering patients in a suicidal process. Nurs Ethics. 2023;30(6):857–70. Lygnugaryte-Griksiene A, Leskauskas D. Assessing suicide management skills of emergency medical services providers before and after suicide intervention/prevention training with Lithuanian version of suicide intervention response inventory. Neuropsychiatr Dis Treat. 2018:3405–12. Lygnugaryte-Griksiene A, Leskauskas D, Jasinskas N, Masiukiene A. Factors influencing the suicide intervention skills of emergency medical services providers. Med Educ Online. 2017;22(1):1291869. Kato R, Okada M. Can financial support reduce suicide mortality rates? Int J Environ Res Public Health. 2019;16(23):4797. Fiksenbaum L, Marjanovic Z, Greenglass E, Garcia-Santos F. Impact of economic hardship and financial threat on suicide ideation and confusion. Mental Health and Psychopathology: Routledge; 2021. pp. 179–98. Evans A, Abrahamson K. The influence of stigma on suicide bereavement: A systematic review. J PsychoSoc Nurs Ment Health Serv. 2020;58(4):21–7. Calear AL, Batterham PJ, Christensen H. Predictors of help-seeking for suicidal ideation in the community: risks and opportunities for public suicide prevention campaigns. Psychiatry Res. 2014;219(3):525–30. Corrigan PW, Sheehan L, Al-Khouja MA, Team SoSR. Making sense of the public stigma of suicide. Crisis. 2017. Mishara BL, Tran AT, Chondo L, Demmer A, Harris-Lane L, Harper S, et al. Evaluation of a Community Suicide Prevention Project (Roots of Hope): Protocol for an Implementation Science Study. JMIR Res Protocols. 2023;12(1):e39978. Ceniti AK, Heinecke N, McInerney SJ. Examining suicide-related presentations to the emergency department. Gen Hosp Psychiatry. 2020;63:152–7. Wong BH-C, Chu P, Calaminus P, Lavelle C, Refaat R, Ougrin D. Association between continuity of care and attendance of post-discharge follow-up after psychiatric emergency presentation. npj mental health Res. 2024;3(1):5. Mousavi SG, Zohreh R, Maracy MR, Ebrahimi A, Sharbafchi MR. The efficacy of telephonic follow up in prevention of suicidal reattempt in patients with suicide attempt history. Adv biomedical Res. 2014;3(1):198. Inagaki M, Kawashima Y, Yonemoto N, Yamada M. Active contact and follow-up interventions to prevent repeat suicide attempts during high-risk periods among patients admitted to emergency departments for suicidal behavior: a systematic review and meta-analysis. BMC Psychiatry. 2019;19:1–11. Che SE, Gwon YG, Kim K-H. Follow-up timing after discharge and suicide risk among patients hospitalized with psychiatric illness. JAMA Netw open. 2023;6(10):e2336767–e. Diniz D, Brito L, Carino G, Ambrogi I. The need for an intersectional lens in health emergencies. Lancet Global Health. 2022;10(1):e37. Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterial.docx Cite Share Download PDF Status: Published Journal Publication published 10 Dec, 2025 Read the published version in BMC Psychiatry → Version 1 posted Editorial decision: Revision requested 13 Aug, 2024 Editor assigned by journal 12 Aug, 2024 Submission checks completed at journal 12 Aug, 2024 First submitted to journal 09 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-4886363\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":339672285,\"identity\":\"88fdcb74-9af6-4e91-9571-937d1add62c7\",\"order_by\":0,\"name\":\"Fatemeh Shirzad\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Iran University of Medical 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PHC\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Figure1.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4886363/v1/44b874293db2c283ee6798c4.jpg\"},{\"id\":66119050,\"identity\":\"9ac72b6e-81bb-49c6-8f7e-9d74bd4c0590\",\"added_by\":\"auto\",\"created_at\":\"2024-10-08 01:13:36\",\"extension\":\"jpg\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":400900,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eThe program's logic model for the Follow-up Care System for Suicide Attempt in Iran\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"2.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4886363/v1/550f6e9a8f3d79e8643d3b63.jpg\"},{\"id\":66118446,\"identity\":\"497ad29b-0ad4-4511-8965-8512ceef3e1d\",\"added_by\":\"auto\",\"created_at\":\"2024-10-08 01:05:36\",\"extension\":\"jpg\",\"order_by\":3,\"title\":\"Figure 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01:05:36\",\"extension\":\"docx\",\"order_by\":8,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":14331,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"SupplementaryMaterial.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4886363/v1/96528ba00b5f1a0607ece5f5.docx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Process Evaluation of the Follow-Up Care System for Suicide Attempt in Iran: A Mixed- Method Study\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eA 40-year-old male patient was transported to a Shahriar city, Tehran province hospital by emergency medical services following a suicide attempt by hanging. He was discharged the same day but subsequently died from injuries sustained in a fall three days later.\\u003c/p\\u003e \\u003cp\\u003eSuch cases underscore the importance of one critical element: implementing effective follow-up systems to ensure the safety and well-being of those who have attempted suicide.(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e) Given the elevated risk of subsequent suicide attempts, timely intervention is paramount. (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e) However, the implementation of effective follow-up support remains a significant challenge. (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003eTo address this critical gap, Iran implemented a nationwide suicide prevention program within its primary health care system in 2010. A core component of this initiative involves providing structured follow-up care for individuals who have attempted suicide, both during hospitalization and post-discharge. (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e) A pilot phase involving intensive post-discharge follow-up for suicide attempt survivors was implemented across four Iranian provinces beginning in early 2017. This model was subsequently expanded nationwide. (\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003eThe program developers reported that the evaluation revealed a significantly lower rate of suicide re-attempts among individuals who fully cooperated with the intervention. This cooperation included answering phone calls and agreeing to in-person visits for four sessions of brief psychological intervention after being referred from the hospital to the Health network. These findings suggest that the program may be effective in reducing suicide re-attempts. However, recent statistics indicate an overall increase in the rate of suicides. For instance, in 2019, there were 5,143 recorded suicides in Iran, representing an 11% increase compared to the 4,625 suicides recorded in 2017.(\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003eSuicide rates have shown a concerning upward trend, necessitating a critical evaluation of existing prevention programs. This concern, coupled with the absence of any process evaluation of the program, motivated us to conduct this research. The current study aims to address the critical gap in knowledge regarding the implementation of this program through a rigorous process evaluation.\\u003c/p\\u003e \\u003cp\\u003ePrevious research has primarily focused on outcomes, with limited attention paid to how programs are actually implemented. A review of 42 papers from six multilevel suicide prevention trials identified a significant dearth of process evaluation. Only four studies included any process evaluation component, and a mere two provided comprehensive details on methodology and results. (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e) This gap is particularly pronounced in the Iranian context, where the overwhelming majority of studies have focused exclusively on program outcomes, with a complete absence of process evaluation.(\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003eProcess evaluation is a systematic method for assessing how well a program is delivered compared to its planned design. It provides valuable insights into program implementation, mechanisms of change, and contextual factors influencing outcomes.(\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003eTo structure our evaluation, we employ the Medical Research Council (MRC) framework, a robust approach for assessing the complexity of health interventions.(\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e) Based on this framework, our study focuses on three key objectives:\\u003c/p\\u003e \\u003cp\\u003eObjective 1: Evaluate program implementation by assessing dose, reach, and fidelity.\\u003c/p\\u003e \\u003cp\\u003eObjective 2: Explore mechanisms of change to understand how the program generates intended effects.\\u003c/p\\u003e \\u003cp\\u003eObjective 3: Identify contextual factors influencing both program implementation and outcomes.\\u003c/p\\u003e\"},{\"header\":\"Method\",\"content\":\"\\u003cp\\u003eStudy design\\u003c/p\\u003e \\u003cp\\u003eThis study, embedded within a larger action research project, employed a mixed-methods explanatory sequential design to evaluate the Follow-Up Care System for Attempted Suicide. Adopting MRC Framework, the study focused on assessing the system's implementation fidelity, dose, and reach, understanding its mechanisms of impact on patients, and examining the influence of contextual factors(\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e) One challenge, as underscored in the full guidance document of MRC, is the absence of a consensus on the optimal division of evaluation into key subcomponents. To address this, we identified seven components based on the MRC framework and previous studies ( Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).(\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eprocess evaluation components, research questions and data sources\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eThemes for process evaluation\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eComponents\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eQuestions\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eData source\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003eImplementation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eReach\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eHow many people attempting suicide are registered in the follow-up system?\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eRoutine monitoring data, Registration Form,\\u003c/p\\u003e \\u003cp\\u003eHealth Record System\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eDoes Delivered\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eHow many sessions of brief psychological intervention were actually delivered to participants?\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eRoutine monitoring data, Registration Form,\\u003c/p\\u003e \\u003cp\\u003eHealth Record System,\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eFidelity\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eTo what extent did the follow-up system adhere to the original design? Were there any deviations in how follow-up system was delivered (e.g., content of sessions, training of providers?\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eChecklist,\\u003c/p\\u003e \\u003cp\\u003eImplementer interview,\\u003c/p\\u003e \\u003cp\\u003eDocument Review\\u003c/p\\u003e \\u003cp\\u003eFocus Groups\\u003c/p\\u003e \\u003cp\\u003esite visits\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eMechanisms of impact\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eAcceptability\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u0026bull;\\u003c/p\\u003e \\u003cp\\u003eTo what extant\\u0026nbsp;participants were satisfied with follow-up system?\\u003c/p\\u003e\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eFocus Groups\\u003c/p\\u003e \\u003cp\\u003eImplementer interview\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eDose received\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eTo what extent did they participate in the intervention sessions and utilize the resources provided?\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eparticipant interviews\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eContext\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eContext\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eHow and in what ways do contextual factors affect the implementation of follow-up system?\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eImplementer interview\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eSettings and participants\\u003c/h2\\u003e \\u003cp\\u003eThis study centered on individuals with a history of suicide attempt and healthcare providers situated within the context of general hospitals and health centers in Shahriar County, Tehran Province. Characterized by a population of 950,000 experiencing rapid growth and significant inward migration, Shahriar County exhibits a prevalence of deprived and marginalized communities, as well as a range of associated socio-economic challenges.(\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003eThe study comprised nineteen mental health workers (MHW), two mental health experts (MHE), sixteen hospital staff members, and eight individuals who had previously attempted suicide. Data pertaining to 992 individuals who had attempted suicide between April and September 2023 were incorporated into the study. These cases were referred to the health network by general hospitals and emergency medical services(EMS).(\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e)\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec4\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eFollow-Up Care System for Suicide Attempt in Iran\\u003c/h2\\u003e \\u003cp\\u003eThe third strategic objective of Iran's comprehensive suicide prevention program aims to enhance the quantity and quality of services provided to individuals at risk of or having attempted suicide. Post-suicide attempt care is primarily managed within the primary care system, facilitated through collaborative efforts between hospitals and health centers (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eUpon presentation to the emergency department, individuals receive diagnostic and therapeutic interventions. When clinically indicated, psychiatric consultation is arranged. Subsequent to a comprehensive evaluation, decisions regarding hospitalization or discharge, accompanied by a psychiatrist-prescribed medication plan, are made. Hospital social workers are mandated to conduct at least one intervention session with each patient and are responsible for informing them about subsequent care at the health center. Ongoing support is provided by hospital social workers until a referral to the health center is established.\\u003c/p\\u003e \\u003cp\\u003eA weekly list of discharged suicide attempters is transmitted to the health network. Mental health experts are obligated to contact these individuals and refer them to the nearest health center. General practitioners at the health center initiate care and subsequently refer patients for psychological interventions delivered by MHWs.\\u003c/p\\u003e \\u003cp\\u003eThe program strives to ensure that all individuals who have attempted suicide and have been referred to mental health experts receive at least one brief psychological intervention session. The proportion of individuals who have attempted suicide, referred from hospitals to the health network, and subsequently receiving at least one brief psychological intervention serves as the evaluation indicator for this objective.\\u003c/p\\u003e \\u003cp\\u003eTo bolster the knowledge and skills of mental health professionals within the PHC system, a comprehensive psychological intervention package for suicide prevention has been developed. Based on \\\"Brief Intervention in Suicide Attempts: A Handbook for Clinicians\\\" (2nd Edition) by Dr. Angela Gaynes Myer and Dr. Konrad Michael, this package outlines a short-term psychological intervention and follow-up strategy comprising 3\\u0026ndash;4 sessions over 2\\u0026ndash;4 weeks. Core components of the intervention include conducting a narrative interview, reviewing the interview findings, identifying patterns leading to the suicide crisis, and re-exposure therapy.\\u003c/p\\u003e \\u003cp\\u003e.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eProcedure and Data Collection\\u003c/p\\u003e \\u003cp\\u003eTo facilitate the development and implementation of the follow-up system, robust partnerships with key stakeholders were cultivated. Collaborative meetings with the university's health department vice-chancellor and the head of Shahriar city's health and treatment network secured essential support for the evaluation. These relationships proved instrumental in understanding the intervention's dynamics and addressing implementation challenges.\\u003c/p\\u003e \\u003cp\\u003eThe evaluation team comprised a multidisciplinary group of four psychiatrists, two psychologists, a community mental health specialist, a methodologist, and two social medicine experts. This diverse expertise enabled comprehensive data collection and analysis, guided by a principal investigator for effective coordination.\\u003c/p\\u003e \\u003cp\\u003eTo establish a clear framework for the evaluation, the follow-up system was meticulously described, including its underlying causal assumptions. Given the initial lack of clarity surrounding the intervention, a logic model was developed in collaboration with intervention developers. This model elucidated the intervention's components and anticipated outcomes, informing subsequent research questions and methodologies.\\u003c/p\\u003e \\u003cp\\u003eCore research questions were formulated based on the intervention's causal assumptions and stakeholder input. This focused approach prioritized critical uncertainties and meaningful outcomes for the evaluation.\\u003c/p\\u003e \\u003cp\\u003eData collection employed a mixed-methods approach, incorporating routine monitoring data, registration forms, implementer self-reports and interviews, document reviews, focus groups, site visits, participant interviews, and stakeholder interviews. This triangulation of data enhanced the study's validity and reliability in assessing the follow-up program. (\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003eData collection was conducted in two phases: quantitative and qualitative.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec5\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eQuantitative Data\\u003c/h2\\u003e \\u003cp\\u003eQuantitative data encompassed the number of health center visits by suicide attempters, intervention session frequency following phone calls, and implementation process details of the follow-up system. These data were extracted from general hospital registration forms, the \\\"SINA\\\" Health Record System's routine monitoring data, and the National Registration System of Suicide Behaviors.\\u003c/p\\u003e \\u003cp\\u003eThe National Suicidal Behavior Registration System captures comprehensive data on suicidal behaviors from hospital-submitted registration forms, informing suicide prevention strategies. The \\\"SINA\\\" health record system documents individuals accessing mental health services, ensuring care continuity.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec6\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eQualitative Data\\u003c/h2\\u003e \\u003cp\\u003eFollowing the completion of the quantitative phase, qualitative data collection commenced. This phase involved interviews, focus groups, self-reports, document reviews, and site visits. Participants for semi-structured interviews and focus groups were selected through purposive sampling. To prioritize participant comfort and privacy, interviews were conducted at either the participants' workplaces or the health network. All interviews were facilitated by trained researchers proficient in qualitative interviewing techniques and were conducted in Persian. A standardized semi-structured interview guide was employed.(\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003eA total of six focus group discussions were conducted: three involving 16 participants from three different hospitals and three comprising MHEs and MHW. Participant diversity was prioritized to enrich the data collected. (\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e) To gain a deeper understanding of the system's practical implementation, site visits were conducted at comprehensive health service centers. Observations and informal conversations with staff during these visits offered valuable insights into daily operations and the challenges encountered by healthcare providers.(\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003eAdditionally, self-reports from MHWs over the past six months were analyzed. Document review encompassed the national suicide prevention program (including resource review, stakeholder analysis, implementation background, goals, strategies, and operational plan), guidelines for providing suicide prevention services within the healthcare system, protocols for short-term psychological intervention and post-discharge follow-up for suicide attempters, and other educational materials intended for mental health professionals.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec7\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eAnalysis\\u003c/h2\\u003e \\u003cp\\u003eQuantitative data on program reach and dose, were analyzed using descriptive statistics.(\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e) Reach and dose were assessed by examining the number of delivered psychological intervention sessions and the proportion of individuals receiving at least one session.\\u003c/p\\u003e \\u003cp\\u003eTo analyze the qualitative data, we employed the Framework Method, a systematic approach commonly used in multidisciplinary healthcare research. This method involved a seven-step process to identify and interpret key themes within the data.. (\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003eInitially, the interviews were transcribed to ensure a comprehensive understanding of the data. Subsequently, familiarization with the interviews was conducted by reviewing both the audio recordings and transcripts. This step allowed for immersion in the data and facilitated the identification of key themes and patterns. Re-listening to the recordings provided further insights into the interview context.\\u003c/p\\u003e \\u003cp\\u003eNext, systematic coding was undertaken. Selected transcripts were meticulously reviewed, and codes were applied to capture significant aspects of the data. Although the MRC framework guided our approach, our coding was not purely deductive, incorporating elements of \\\"open coding\\\" to allow for the emergence of new themes.\\u003c/p\\u003e \\u003cp\\u003eFollowing the coding process, a working analytical framework was developed. Researchers convened to compare and consolidate the codes applied to the transcripts, thereby forming a cohesive framework. This analytical framework was then applied to subsequent transcripts through the process of indexing, ensuring consistency and depth in the analysis.\\u003c/p\\u003e \\u003cp\\u003eMAXQDA was utilized to streamline this process, enhancing both efficiency and organization. The data was then charted into a framework matrix, with a spreadsheet summarizing the data by category from each transcript. This matrix incorporated illustrative quotations to facilitate deeper analysis and interpretation. Subsequently, the data was classified within the MRC framework.\\u003c/p\\u003e \\u003cp\\u003eThe final step involved data interpretation, guided by early impressions and ideas noted throughout the analysis. Characteristics and differences within the data were identified, leading to the generation of findings that extended beyond mere description. This stage involved exploring themes, generating typologies, and examining theoretical concepts to provide comprehensive insights into the implementation process and its impact. To ensure the rigor of our data analysis, we adhered to the criteria for trustworthiness outlined by Guba and Lincoln. (\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e)\\u003c/p\\u003e \\u003c/div\\u003e \"},{\"header\":\"RESULTS\",\"content\":\"\\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003cp\\u003eThe results are presented in two sections: quantitative and qualitative. Prior to initiating the evaluation, we developed the program's logic model, as illustrated in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec9\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eQuantitative Results\\u003c/h2\\u003e \\u003cdiv id=\\\"Sec10\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eAccess:\\u003c/h2\\u003e \\u003cp\\u003eA total of 992 individuals who attempted suicide were referred from general hospitals to health network between April and September 2023. Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e presents the demographic characteristics of these individuals.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eDemographic characteristics\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"2\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDemographic Variables\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e992\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eAge\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e29\\u0026middot;9\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;12\\u0026middot;04\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMin.-Max.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(11\\u0026ndash;81)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eSex\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMale\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e391 (39\\u0026middot;41%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003efemale\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e589 (59\\u0026middot;37%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUnknown\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e12 (1\\u0026middot;2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eMarital Status\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSingle\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e211 (21\\u0026middot;27%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMarried\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e255 (25\\u0026middot;7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDivorced\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e27 (2\\u0026middot;72%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUnknown\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e499 (50\\u0026middot;3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eOf the 992 individuals referred, contact was established with 903. Among these, 525 answered the phone directly. In cases where contact was unsuccessful, reasons included incorrect phone numbers, unanswered calls, or switched-off phones. Out of the 525 who answered, 178 were the individuals who attempted suicide, while 347 were other respondents. A total of 15 individuals accessed and completed at least one brief psychological intervention session offered at health centers, demonstrating limited program reach. Further details and information are available in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eDelivered Dose:\\u003c/p\\u003e \\u003cp\\u003eThe intervention protocol included 3 to 4 sessions delivered over a 2 to 4-week period for each participant. While all 15 participants began the intervention, attendance declined over time. Eight participants attended the second session, four attended the third, and only three completed all four sessions\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eQualitative Results:\\u003c/h2\\u003e \\u003cp\\u003eThrough inductive analysis of interview data, nine categories emerged, which were subsequently aligned with the MRC framework themes. (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eCategories resulting from qualitative analysis\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"2\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCategory\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMRC Theme\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eInfrastructure\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003eImplementation\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eInformation gap\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHuman resource\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eParticipant experiences\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eMechanisms of impact\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eProgram acceptability\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSocioeconomic Factors\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\" morerows=\\\"3\\\" rowspan=\\\"4\\\"\\u003e \\u003cp\\u003eContext\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eStigma and lack of awareness\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eOrganizational issues\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEasy access to means of suicide\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eReach\\u003c/h2\\u003e \\u003cp\\u003eMultiple factors contributed to low program accessibility, as revealed through interviews and observations. A primary challenge was ineffective communication between general hospitals and health centers, resulting in information gaps. Furthermore, initial contact with suicidal individuals often occurs through Emergency Medical Services (EMS), who, due to urgent medical priorities, are unable to gather comprehensive patient information, hindering subsequent follow-up.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;When EMS brings in an emergency patient, they might not even give us a name and bring them in as anonymous patients. The emergency department records any information the patient provides to them, and most cases we handle are usually like this.\\\" (Hospital nurse)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003eAfter the individual is taken to the hospital emergency department via EMS, there is another opportunity during admission to collect their information. However, even at this stage, there are deficiencies, and the information sent to health centers often lacks demographic variables such as marital status, employment status, educational status, and even the national ID and phone number of the individual. The form provided to hospitals to send individuals' information to the health network is comprehensive but is not fully completed.\\u003c/p\\u003e \\u003cp\\u003eAdditionally, a critical oversight exists in differentiating between accidental and intentional poisonings. Currently, the reason for poisoning is documented without clarifying intent, hindering accurate data analysis and targeted interventions. While hospital staff informally exclude cases of accidental poisoning and alcohol consumption, a standardized, comprehensive system for this distinction is absent.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"Some cases are removed from the list based on the doctor's opinion. This is because the individual says they did not intend to commit suicide; they simply took more pills by mistake. Since the EMS service does not take a detailed history and labels everyone as a suicide attempt.\\\" (Hospital staff)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003eFollowing the transmission of data to the health network, as outlined in the protocol, MHWs encounter significant challenges at the health center level. The absence of complete patient information severely hinders their ability to reach individuals for follow-up care.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;Even cases that have phone numbers may be incorrect, unavailable, or unreachable, or the number may even belong to a neighbor who contacted the emergency services.\\\" (MHW)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"Suicide cases are reported from hospitals to the network, and the list that comes from the emergency services almost has nothing except the name, address, age\\\" (MHE)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003eCompounding this issue, MHWs report the presence of duplicate and conflicting patient records across various lists. Discrepancies in patient age, details, and even overlapping names in both emergency and hospital lists impede accurate data management. These challenges, combined with infrastructural limitations such as shared consultation rooms for MHWs and nutritionists, further restrict patient accessibility and continuity of care.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"Our center only has one phone line. Firstly, in the mornings, we cannot make calls and have to wait until noon to call people, and since we only have one line, making calls becomes difficult. The line gets busy.\\\" (MHW)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"Not having a phone line significantly affects us. It makes calling difficult, and sometimes some colleagues have to use their personal phones to make calls, which itself causes problems.\\\" (MHW)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003eNotably, inconsistent approaches to initial contact were observed among MHWs. While some practitioners adopted a sensitive, indirect approach, others used direct language disclosing the reason for the call. These varying methodologies highlight the need for standardized guidelines for initial contact and obtaining consent.\\u003c/p\\u003e \\u003cp\\u003eSome notes from MHWs following their calls to participants are presented in Supplementary 1.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eFidelity\\u003c/h2\\u003e \\u003cp\\u003eInterview results reveal a significant lack of program fidelity, particularly within the hospital sector. Psychological care is notably underemphasized, often overshadowed by a focus on physical health. This disparity is alarmingly evident in cases involving high-lethality suicide attempts, where patients without physical injuries may be discharged due to the absence of psychiatric and psychological professionals.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"If we see that the individual might attempt suicide after being discharged, the only thing we can really do is refer them to the health network so they can use mental health services.\\\" (Hospital staff)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003eThe scarcity of psychiatric beds in Shahriar\\u0026rsquo;s public hospitals necessitates referrals to specialized psychiatric facilities, further underscoring the system\\u0026rsquo;s limitations. Moreover, a shortage of social workers, as reported by hospital staff, exacerbates the issue.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"We need to hire a nurse specifically for suicide cases. For example, we have someone here who follows up on hypertension cases. Suicide is much more complicated because, in hypertension, the person acknowledges they have a problem and listens to whatever you say.\\\" (Hospital nurse)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"We don't have a poisoning department, nor do we have a psychiatrist or psychologist. Once their initial treatment is done, they are sent to a psychiatric hospital. If they personally consent, they are discharged. Hanging cases, once they are physically stable, are coordinated to be transferred.\\\" (Hospital nurse)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"For example, I referred a case to Iran Psychiatric Hospital, and the doctor wrote that the person has a problem and needs hospitalization, but they don't have any available beds.\\\" (Hospital nurse)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"I am just a social worker, and I am not always in the hospital. I think there should be coverage by shifts in all hospitals. We don't have a social worker in all shifts; practically, during holidays and night shifts, the nursing supervisor takes on the role of the social worker, and well, many things cannot be thoroughly examined from other aspects.\\\" (Hospital social worker)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003eDespite protocol mandates for weekly reporting of suicide cases to the health network, mental health experts indicate that this information is currently submitted on a monthly basis. Additionally, healthcare centers demonstrate substantial deviations from intervention protocols, with sessions and materials frequently failing to adhere to guidelines.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"The protocol states that contact should be made with MHE at the health network, and then those who have expressed readiness should be referred to us for MHWs. But currently, they just give us the names and we have to make the calls.\\\" (MHW)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"Many times, we cannot even perform the tasks requested of us. For example, we have to give tasks to clients. Sometimes they are illiterate, sometimes they are children, and these tasks are too heavy for them, and they cannot understand and do them.\\\" (MHW)\\u003c/em\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eMechanisms of Impact\\u003c/h2\\u003e \\u003cdiv id=\\\"Sec15\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eAcceptance\\u003c/h2\\u003e \\u003cp\\u003eOpinions among MHWs diverge regarding the efficacy of follow-up care for individuals who have attempted suicide. Some professionals assert that delays in administrative processes often hinder the effectiveness of these follow-ups, leading to minimal improvement in the individual's psychological state.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"Generally, the follow-up of individuals who have attempted suicide in any way must be done, but these phone follow-ups, which, due to administrative delays, occur long after the suicide, are practically useless.\\\" (MHW)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003eMHWs highlighted the substantial gap between a suicide attempt and subsequent follow-up sessions as a significant challenge.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"The follow-up of suicide cases within 2 to 3 months after the attempt is not beneficial and effective because the individual's mental and emotional conditions change over time, and they may not feel the need for counseling or treatment.\\\" (MHW)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003eSome interviewees questioned the utility of these follow-ups, particularly for individuals grappling with financial or familial crises.\\u003c/p\\u003e \\u003cp\\u003e\\u003cem\\u003e \\\"If you ask me, it's pointless, especially in this region, because when someone like Ms. X comes in, who doesn't even have money to see a doctor or eat, how does psychological intervention and self-care help this patient when they are still struggling with basic needs? Sometimes I really don't know what to say when they tell me they don't have anything to eat, and I suggest counseling, but it doesn't help.\\\" (MHW)\\u003c/em\\u003e\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"During my 10 months of service so far, only 3 people from the lists have come for consultation, and most of them are in high-stress families or have addicted caretakers, facing difficult financial and life conditions. They thought we could help them financially, but after realizing that's not the case, they stopped coming.\\\" (MHW)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003eAdditionally, the high turnover rate among MHWs was identified as a barrier to effective long-term care.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;Our MHWs are constantly relocating. Psychology is about building relationships. You settle into a center, establish connections with clients, and then after a few months, they send you to another center, and you lose touch with your previous clients.\\\" (MHW)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003eDespite these limitations, some interviewees acknowledged the potential benefits of follow-ups, such as increased awareness of available resources, family education, and emotional support.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"It seems beneficial to me that we can help even one person and raise awareness. Providing education to families is valuable. I believe I have been able to establish connections with everyone who attempted and raise their awareness.\\\" (MHW)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"One of the experiences I have from follow-ups is about a teenage boy who had attempted suicide multiple times. He came with his father, and with the interventions we provided, he found motivation to continue his education and also decided to work in a store due to financial difficulties.\\\" (MHW)\\u003c/em\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec16\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eReceived Dose\\u003c/h2\\u003e \\u003cp\\u003eWhile service providers expressed mixed views, participants overwhelmingly reported positive experiences with the program. Despite the limited sample size, this group consistently described significant improvements in stress management and a decrease in suicidal ideation.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"I attended several sessions, and thankfully, it was good. Talking to the therapist calmed me down. They also taught me about parenting. Then, they talked to my husband as well. They referred me to a psychiatrist, and now I am taking medication.\\\" (Service user)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"These sessions helped me know what to do when suicidal thoughts came to me. Previously, when I didn't know these techniques, I used to get very upset.\\\" (Service user)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"The psychologist puts in a lot of effort, but there are some bigger problems that I have that they can't solve. If these problems are solved, my situation would be much better.\\\" (Service user)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003eHowever, participants commonly cited EMS and hospital emergency department, as areas requiring improvement.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"It wasn't very helpful when EMS arrived and asked me why I attempted suicide. Then, when I went to the hospital, even though my mental state wasn't good, they discharged me.\\\" (Service user)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003eAlso participants frequently identified gender dynamics and domestic violence as significant barriers to accessing healthcare services, highlighting these issues as particularly problematic for women.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"After someone from the health center called, asked about my well-being, and suggested I attend a counseling session, I felt happy and realized I wasn't alone\\u0026rdquo; (Service user)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"Most of the time, I go to the psychologist in secret and try not to let my husband know because he is against it. But these sessions do help me.\\\" (Service user)\\u003c/em\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec17\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eContext\\u003c/h2\\u003e \\u003cp\\u003eThe implementation and effectiveness of the suicide prevention program were significantly influenced by contextual factors. Lack of awareness and prevailing stigma emerged as key barriers, with individuals often hesitant to recognize warning signs or seek help due to fear of judgment. Families also contributed to the challenge by denying suicide attempts or withholding relevant information.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"Families usually do not mention suicide due to its taboo nature. There have been cases where we have contacted families for follow-up and they have denied it, saying that the person took the pills accidentally and even asking us not to register it as a suicide attempt.\\\" (MHW)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003e\\u0026ldquo;\\u003c/b\\u003e \\u003cem\\u003eThis electronic registration also causes problems for us. Families come and say why we registered it in the system and they think it will cause problems for them\\u003c/em\\u003e.\\u003cb\\u003e\\\"\\u003c/b\\u003e \\u003cem\\u003e(MHW)\\u003c/em\\u003e\\u003c/p\\u003e \\u003cp\\u003eMoreover, easy access to suicide methods was identified as a concerning factor.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"Last week, they brought in a 15-year-old girl who had taken rice pills purchased from a herbal shop. There needs to be more supervision on these things.\\\"(Hospital staff)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003eFinancial constraints, including insurance limitations, were reported as obstacles to accessing necessary treatment and follow-up care.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"Cost is a major issue for us. Most of these individuals don't have insurance, so when they need counseling, they have to pay for it themselves. Not having a mental health unit is very challenging for us.\\\" (Hospital nurse)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"Some who don't have money and get hospitalized until they regain consciousness escape from the hospital, and then it's impossible to continue their follow-up care.\\\" (Hospital staff)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;We had a person with suicidal thoughts, but they didn't have money to go to a psychiatrist.'\\\" (MHW)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"The main reason for suicide attempts in the area is poverty and addiction. As long as we don't have financial support, people won't come to us or trust us. There was someone who attended all sessions, and we helped them, but out of 10 people, maybe 1 person comes, and even that is uncertain... I followed up with one of the clients five times before they came.\\\" (MHW)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003eCultural factors, particularly those related to gender, were highlighted as impediments to program implementation, with MHWss emphasizing the impact of gender-based issues.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\u0026ldquo;Sometimes when I call a woman and her husband or brother answers, they get angry and ask why I called and where I got the number.\\\" (Male MHW)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"Many times, a woman who has attempted suicide has also been a victim of domestic violence, and her husband does not allow her to come to the sessions, which makes it very challenging for us to intervene in such cases. Even if we contact the police or social services, it usually doesn't yield much result.\\\" (MHW)\\u003c/em\\u003e \\u003c/p\\u003e \\u003cp\\u003eOrganizational changes also hindered program implementation and evaluation. For instance, the EMS department discontinued providing suicide statistics from September 2023 onward, impacting data collection and analysis.\\u003c/p\\u003e \\u003cp\\u003e \\u003cem\\u003e\\\"Since the emergency department became independent, we haven't received suicide statistics for months now. This doesn't mean that suicides have decreased; it's because the emergency department hasn't provided us with suicide statistics for several months now.\\\" (MHE)\\u003c/em\\u003e \\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"DISCUSSION\",\"content\":\"\\u003cp\\u003eRigorous evaluation of suicide prevention programs is essential for optimizing their efficacy and enhancing mental health outcomes. This study undertook a process evaluation of a post-suicide attempt follow-up system in Iran, examining implementation fidelity, mechanisms of impact, and contextual determinants. Findings revealed significant challenges in program delivery. Quantitative data indicated suboptimal stakeholder access, low service utilization, and poor adherence to program protocols. The qualitative section explored the underlying reasons for these challenges, which will be discussed in detail.\\u003c/p\\u003e \\u003cp\\u003eA meta-analysis of over 500 quantitative studies underscores the critical role of implementation fidelity in determining the outcomes of promotion and prevention programs.(\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e) Achieving adequate reach within the target population is a fundamental aspect of program implementation. Consequently, calculating participation rates is essential for assessing the potential impact of interventions. (\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e) By meticulously examining reach and participation, programs can refine their strategies to optimize engagement and effectiveness.(\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e) Moreover, tailoring program components to the specific characteristics and needs of diverse demographic groups is imperative for maximizing inclusivity and participation.(\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003eThe evaluation uncovered substantial gaps in program fidelity across both hospital and health centers. Hospitals exhibited a critical dearth of essential resources, including the absence of on-call psychiatrists, insufficient social workers, and a complete lack of psychiatric inpatient beds. These deficiencies represent a stark deviation from the program's outlined provisions. Despite a Ministry of Health mandate allocating 10% of hospital beds to psychiatric care, Shahriar city currently lacks any psychiatric inpatient facilities. In primary care centers, program implementation also fell short of expectations. Notably, the program's design disproportionately burdens primary care facilities with follow-up responsibilities, contrasting with the hospital-centric approach common in other countries. (\\u003cspan additionalcitationids=\\\"CR27 CR28\\\" citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003eThe identified systemic deficiencies culminate in substantial delays between suicide attempts and the initiation of follow-up care, often extending to as much as three months. Given the critical importance of timely intervention in suicide prevention, these delays significantly compromise the program's effectiveness. This protracted response stands in stark contrast to evidence-based guidelines from programs such as the National Suicide Prevention Lifeline in the USA and the LifeSpan program in Australia, which emphasize the need for follow-up within 72 hours of discharge. (\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e) A study revealed that only 30.9% of individuals discharged from U.S. hospitals following hospitalization for suicidal ideation, attempts, or self-harm initiated outpatient mental health treatment within a week of discharge. (\\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003eThe program's efficacy has been questioned by certain service providers, raising concerns regarding its overall acceptability. Conversely, proponents have emphasized the potential advantages of follow-up services in terms of emotional support and awareness enhancement. Also, interviews with survivors of suicide attempts indicated that the intervention contributed to improved coping mechanisms and a reduction in suicidal ideation.\\u003c/p\\u003e \\u003cp\\u003eIt is crucial to consider that negative feedback from MHWs may not necessarily reflect shortcomings of the program itself but rather implementation challenges. For example, high turnover rates among MHWs can impede the delivery of optimal services, particularly in mental health contexts where establishing a strong therapeutic alliance is fundamental to effective intervention. .(\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003eThe experiences of individuals facing EMC have not always been favorable. Multiple studies emphasize the importance of establishing a patient-provider relationship and understanding the psychological state of patients, including those with suicidal thoughts(\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e) To improve suicide intervention skills among EMS providers, emphasis should be placed on their attitudes towards suicide prevention, stress management skills, ongoing training in suicide intervention techniques, active listening skills, empathetic communication, and compassionate attention. (\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003eThe study underscored the profound influence of contextual factors, including socioeconomic conditions, gender dynamics, infrastructural limitations, accessibility to suicide-related means, and systemic barriers, on program implementation and efficacy. These findings underscore the critical role of addressing social determinants of health and tailoring interventions to the specific needs of vulnerable populations. A study on financial support for regional suicide prevention programs in Japan found a positive correlation between increased budgetary allocations and decreased suicide rates (\\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e) These findings suggest that investing in suicide prevention programs can effectively reduce rates, highlighting the importance of alleviating financial burdens as part of the strategy. (\\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003eOur findings demonstrate that cultural norms and gender roles significantly influence help-seeking behaviors and access to mental healthcare in contexts such as Iran. This underscores the imperative for culturally tailored interventions that directly address these barriers. Also Stigma emerged as a pervasive challenge hindering the effective implementation of suicide prevention programs. Notably, stigma impacts both individuals who have attempted suicide and their surrounding communities. Survivors of suicide loss often endure shame, blame, and societal judgment, fostering isolation and hindering the grieving process. (\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e) On the other hand, the fear of social disapproval and negative consequences associated with suicide attempts deter individuals from seeking help, potentially exacerbating their mental health crisis.. (\\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003eOur study exemplifies the potential for unintended consequences arising from organizational changes within healthcare systems. Specifically, alterations to emergency department reporting procedures have adversely impacted the availability of critical data for program monitoring and evaluation. Given the established importance of robust data collection for effective suicide prevention these changes pose a significant challenge. (\\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003eIran's PHC system mandates the oversight of health centers and public hospitals by the Health Network. However, the Health Network in Shahriar County currently lacks the authority to effectively influence public hospitals, creating a significant governance gap that hinders coordinated service delivery.\\u003c/p\\u003e \\u003cp\\u003eOur recommendation for following up on suicide attempts is to conduct these follow-ups within the hospital itself. Findings indicate that hospital emergency departments can serve as pivotal focal points for suicide intervention therapies. (\\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e) Results of a study in England showed that continuity of care by the same clinician who saw the patient in the hospital can significantly increase the likelihood of the patient attending subsequent appointments.(\\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e) This underscores that even the specific healthcare provider is important, let alone changes in the location.\\u003c/p\\u003e \\u003cp\\u003eWhen immediate in-hospital follow-up is not possible, better coordination with the health network is essential. This can be done through a unified referral system that registers hospitalized individuals daily, allowing healthcare providers to initiate same-day contact. Discharging patients without collecting crucial information overlooks a vital opportunity for intervention. Enhanced information completeness and active follow-up calls would significantly improve program effectiveness.\\u003c/p\\u003e \\u003cp\\u003eResearch in Iran underscores that even telephone follow-ups for individuals with a history of suicide can markedly reduce suicidal ideation and significantly increase life satisfaction (\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e) Similarly, in other countries, interventions such as \\\"active contact and follow-up\\\" have been shown to reduce the risk of repeated suicide attempts among patients hospitalized in emergency departments. (\\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003eIn the second part, strengthening infrastructure is identified as a critical step toward enhancing the effectiveness of this program. This includes the provision of facilities such as dedicated rooms for mental health professionals and equipping health centers with telephone lines to facilitate easier access to individuals. Additionally, hospital compliance with mandates, such as allocating 10% of beds to psychiatric patients and designating specific psychiatric beds, is an essential measure.\\u003c/p\\u003e \\u003cp\\u003eMoreover, bolstering human resources, including the presence of social workers, psychiatrists, and psychologists in hospitals, is fundamental for the successful implementation of these programs. Detailed guidelines for follow-up procedures, including protocols for conducting initial calls, can significantly increase access to critical care. Implementing mechanisms for gathering feedback from patients can also improve follow-up processes and overall care quality.\\u003c/p\\u003e \\u003cp\\u003ePrioritizing comprehensive training for nurses and EMS staff is crucial in enhancing mental health care delivery. Promoting mental health education and augmenting budgets allocated to mental health services can significantly improve care processes. Furthermore, enhancing insurance coverage for mental health services and enforcing stringent regulations on access to means of suicide are additional measures that warrant consideration.\\u003c/p\\u003e \\u003cp\\u003eAlso our study suggests a need to expand current models of help-seeking behavior by incorporating cultural and structural factors. An intersectional lens reveals how discrimination and marginalization shape access to suicide prevention services, emphasizing the importance of addressing systemic inequalities in mental healthcare.(\\u003cspan citationid=\\\"CR47\\\" class=\\\"CitationRef\\\"\\u003e47\\u003c/span\\u003e)\\u003c/p\\u003e \\u003cp\\u003eThis is the first study in Iran to present a structured and systematic approach using a comprehensive evaluation framework for assessing the suicide surveillance system and, more broadly, the national suicide prevention program. Through this evaluation, we have provided valuable evidence for policymakers to review and address foundational and operational barriers to the program's implementation.\\u003c/p\\u003e \\u003cp\\u003eOne limitation of this study is its reliance on data from a short follow-up period after suicide attempts. While this provides a significant dataset, it may limit the generalizability of the findings. Additionally, the small sample size of participant experiences, due to accessibility constraints, may overrepresent individuals with positive outcomes. Furthermore, the absence of outcome evaluation restricts the depth of analysis. Future research should include outcome assessments and replicate the study nationally to enhance the generalizability of results. Also, Exploring innovative interventions, such as digital tools and remote healthcare services, alongside traditional approaches, should be prioritized.\\u003c/p\\u003e\"},{\"header\":\"Conclusions\",\"content\":\"\\u003cp\\u003eThe process evaluation provided valuable insights into the strengths and weaknesses of the suicide prevention program and highlighted areas for improvement. Importantly, we cannot definitively state whether the program is good or not. If a program is not properly implemented, we cannot determine its effectiveness. Negative outcomes may be due to poor implementation rather than the program itself. The program offers a crucial resource for Shahriar residents at risk of suicide, who often grapple with compounded challenges stemming from socioeconomic factors. To maximize its impact, we need to strengthen program implementation, allocate sufficient resources, build community partnerships, and advocate for policy changes that address the root causes of these issues.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cdiv class=\\\"DefinitionList\\\"\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eMental health workers\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eMHW\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eMental health experts\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eMHE\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003ePrimary health care\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003ePHC\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eand emergency medical services\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eEMS\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003c/div\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e \\u003ch2\\u003eHuman Ethics and Consent to Participate declaration\\u003c/h2\\u003e \\u003cp\\u003e Full explanations were given to the participants about the research and their consent was obtained to participate in the study.This study was approved by the Ethics Committee of Iran University of Medical Sciences, reference number IR.IUMS.REC.1403.311\\u003c/p\\u003e \\u003c/p\\u003e\\u003cp\\u003e \\u003ch2\\u003eConsent for publication\\u003c/h2\\u003e \\u003cp\\u003e Informed consent was obtained from all participants prior to their inclusion in the study.\\u003c/p\\u003e \\u003c/p\\u003e\\u003cp\\u003e \\u003ch2\\u003eCompeting interests\\u003c/h2\\u003e \\u003cp\\u003eWe declare no competing interests.\\u003c/p\\u003e \\u003c/p\\u003e\\u003ch2\\u003eFunding\\u003c/h2\\u003e \\u003cp\\u003e This research was funded by HSR committee, grant number 1403-1-8-27910. The funder had no role in the design of the study; in the collection, analysis, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.\\u003c/p\\u003e\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\u003cp\\u003eFS, AK and MN were the designers of this study, and FS, along with AK, was responsible for managing and executing the project. AK, MN, and PA were involved in the quantitative data analysis. AK, PA, and SZ conducted and analyzed interviews and focus group sessions, cleaned and validated the data. MN and FF were responsible for inter-departmental coordination. FF, FS, VSH, AH, and MN critically reviewed and finalized the manuscript. FS and MN had access to the data and verified it. FF, FS, MN, AH, and VS supervised the project. SZ PA, and AK prepared the first draft. All authors reviewed and approved the final version, had full access to all data, and had the ultimate responsibility for the decision to submit for publication.\\u003c/p\\u003e\\u003ch2\\u003eAcknowledgement\\u003c/h2\\u003e\\u003cp\\u003eWe would like to express our sincere gratitude to all those who participated in this study and contributed to its successful completion. We are particularly grateful to the vice-chancellor of the university's health department for his support in conducting this evaluation. We also extend our thanks to the MHWs, healthcare workers, hospital staff members, and recipients who participated in the study. Their willingness to share their experiences and insights was invaluable.\\u003c/p\\u003e\\u003ch2\\u003eData Availability\\u003c/h2\\u003e\\u003cp\\u003eDue to the sensitive nature of the data related to suicide, and in accordance with confidentiality regulations in Iran, we are unable to make this information publicly available. However, we are prepared to provide the data to referees and journal editors upon request.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eDoupnik SK, Rudd B, Schmutte T, Worsley D, Bowden CF, McCarthy E, et al. Association of suicide prevention interventions with subsequent suicide attempts, linkage to follow-up care, and depression symptoms for acute care settings: a systematic review and meta-analysis. JAMA psychiatry. 2020;77(10):1021\\u0026ndash;30.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMadsen T, Erlangsen A, Hjorth\\u0026oslash;j C, Nordentoft M. High suicide rates during psychiatric inpatient stay and shortly after discharge. Acta psychiatrica Scandinavica. 2020;142(5):355\\u0026ndash;65.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eO\\u0026rsquo;Connor RC, Portzky G. Looking to the future: A synthesis of new developments and challenges in suicide research and prevention. Front Psychol. 2018;9:2139.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eOrganization WH. National suicide prevention strategies: Progress, examples and indicators. 2018.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMalakouti K, Nojomi M, Ghanbari B, Karimi H, Rasouli N, Fathi M, et al. Scaling up the Health System at Provincial Level to Conduct Telephone Follow-Up Program for Suicide Reattempters in West Azerbaijan, Iran, 2017\\u0026ndash;2018. J Suicide Prev. 2020;2(1):3\\u0026ndash;14.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSouresrafil A, Mirzaei M, Rezaeian M. Suicidal behavior in Iran. Suicidal Behavior in Muslim Majority Countries: Epidemiology. 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Process evaluation of complex interventions: Medical Research Council guidance. BMJ. 2015;350.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLiu H, Mohammed A, Shanthosh J, Laba T-L, Hackett ML, Peiris D, et al. Process evaluations of primary care interventions addressing chronic disease: a systematic review. BMJ open. 2019;9(8):e025127.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eJong ST, Brown HE, Croxson CH, Wilkinson P, Corder KL, van Sluijs EM. GoActive: a protocol for the mixed methods process evaluation of a school-based physical activity promotion programme for 13\\u0026ndash;14year old adolescents. Trials. 2018;19:1\\u0026ndash;11.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMahdnejad H, Zanganeh A, Saeidirezvani N. 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Adv biomedical Res. 2014;3(1):198.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eInagaki M, Kawashima Y, Yonemoto N, Yamada M. Active contact and follow-up interventions to prevent repeat suicide attempts during high-risk periods among patients admitted to emergency departments for suicidal behavior: a systematic review and meta-analysis. BMC Psychiatry. 2019;19:1\\u0026ndash;11.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eChe SE, Gwon YG, Kim K-H. Follow-up timing after discharge and suicide risk among patients hospitalized with psychiatric illness. JAMA Netw open. 2023;6(10):e2336767\\u0026ndash;e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDiniz D, Brito L, Carino G, Ambrogi I. The need for an intersectional lens in health emergencies. Lancet Global Health. 2022;10(1):e37.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-psychiatry\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bpsy\",\"sideBox\":\"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/bpsy/default.aspx\",\"title\":\"BMC Psychiatry\",\"twitterHandle\":\"@BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Process Evaluation, Suicide, Iran\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-4886363/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-4886363/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e \\u003cp\\u003eDespite ongoing efforts to provide hospital and post-discharge care for suicide attempters in Iran, national suicide rates continue to exhibit a concerning upward trend. This study employs the MRC framework, a comprehensive evaluation tool, to conduct a process evaluation of Iran's suicide follow-up care system in Shahriar city.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eWe examined fidelity, dosage, reach, impact, and contextual determinants of the program. An explanatory sequential design was employed. Data from 992 suicide attempt cases collected between April and September 2023. Semi-structured interviews were conducted with 19 mental health workers, 2 mental health experts, 16 hospital staff members, and 8 individuals with who have suicide attempts.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eFindings indicated that of the 992 individuals referred for receive services, only a small number (n\\u0026thinsp;=\\u0026thinsp;15) engaged with designated health centers, with a completion rate of a mere 3 individuals, suggesting significant limitations in program reach. Qualitative analysis revealed nine thematic domains aligned with the MRC framework: infrastructure, information gaps, and human resource challenges within implementation mechanisms; participant experiences, and acceptability, related to impact mechanisms; and socioeconomic factors, stigma, organizational barriers, and access to means restriction as contextual components.\\u003c/p\\u003e\\u003ch2\\u003eConclusion\\u003c/h2\\u003e \\u003cp\\u003eThis study in Iran offers a unique contribution by employing a comprehensive framework to systematically evaluate the national suicide follow-up system, its role within broader prevention efforts, and strategies to enhance program effectiveness. The Follow-Up Care System for Suicide Attempt provides a crucial resource for Shahriar residents at risk of suicide, who often grapple with compounded challenges stemming from socioeconomic factors. Our findings underscore critical operational and contextual barriers, providing essential evidence for policymakers to address. While demonstrating initial promise, the program requires substantial improvements. To maximize its impact, we need to strengthen program implementation, allocate sufficient resources, build community partnerships, and advocate for policy changes that address the root causes of these issues.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Process Evaluation of the Follow-Up Care System for Suicide Attempt in Iran: A Mixed- Method Study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2024-10-08 01:05:31\",\"doi\":\"10.21203/rs.3.rs-4886363/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2024-08-13T10:53:22+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2024-08-12T12:23:36+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2024-08-12T12:21:47+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Psychiatry\",\"date\":\"2024-08-09T10:24:24+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-psychiatry\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bpsy\",\"sideBox\":\"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/bpsy/default.aspx\",\"title\":\"BMC Psychiatry\",\"twitterHandle\":\"@BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"90842eac-4ed1-4ae7-9a66-5a0ed5520c73\",\"owner\":[],\"postedDate\":\"October 8th, 2024\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-12-15T16:08:42+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-4886363\",\"link\":\"https://doi.org/10.1186/s12888-025-07687-2\",\"journal\":{\"identity\":\"bmc-psychiatry\",\"isVorOnly\":false,\"title\":\"BMC Psychiatry\"},\"publishedOn\":\"2025-12-10 15:58:59\",\"publishedOnDateReadable\":\"December 10th, 2025\"},\"versionCreatedAt\":\"2024-10-08 01:05:31\",\"video\":\"\",\"vorDoi\":\"10.1186/s12888-025-07687-2\",\"vorDoiUrl\":\"https://doi.org/10.1186/s12888-025-07687-2\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-4886363\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-4886363\",\"identity\":\"rs-4886363\",\"version\":[\"v1\"]},\"buildId\":\"ehx78VzkSd0WSzXnipQa-\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}