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Suicide Prevention Training for

Professionals in the Public Health
Network in a Large Brazilian City
a a
Carlos Filinto da Silva Cais , Isabel Ugarte da Silveira , Sabrina
a a
Stefanello & Neury José Botega
a
Department of Medical Psychology and Psychiatry, School of
Medical Sciences , Universidade Estadual de Campinas , Campinas,
Brazil
Published online: 24 Oct 2011.

To cite this article: Carlos Filinto da Silva Cais , Isabel Ugarte da Silveira , Sabrina Stefanello & Neury
José Botega (2011) Suicide Prevention Training for Professionals in the Public Health Network in a
Large Brazilian City, Archives of Suicide Research, 15:4, 384-389, DOI: 10.1080/13811118.2011.616152

To link to this article: http://dx.doi.org/10.1080/13811118.2011.616152

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 Archives of Suicide Research, 15:384–389, 2011
Copyright # International Academy for Suicide Research
ISSN: 1381-1118 print=1543-6136 online
DOI: 10.1080/13811118.2011.616152

Suicide Prevention
Training for Professionals
in the Public Health
Network in a Large
Brazilian City
Carlos Filinto da Silva Cais, Isabel Ugarte da Silveira,
Downloaded by [64.66.26.185] at 13:37 03 June 2014

Sabrina Stefanello, and Neury José Botega

The objective of this study was to improve health professionals’ knowledge and
attitudes toward suicide prevention. A suicide prevention training of 18 hours
duration was conducted with 270 health professionals, mainly primary care
workers, who were routinely involved with patients at high risk for suicide. Ques-
tionnaires were used to assess changes in attitudes and knowledge. The score in
the knowledge questionnaire, with 21 points as maximum value, increased from
8.9 to 13 points (p < .001, significance level of 95%). Of the 25 questionnaire
items representing attitudes, 18 showed significant change after the training. This
training model has enhanced knowledge and attitudes toward suicide prevention
in healthcare workers.
Keywords attempted suicide, behavior, mental health, primary prevention, self-injurious
behavior, suicide

INTRODUCTION changes in attitudes (e.g., Botega, da Silva,

The medical literature on suicide preven-
tion training for general clinicians and
mental health or general health profes-
sionals is mostly positive (e.g., Szanto,
Kalmar, Hendin et al., 2007), with only a
few studies failing to meet their goals
(e.g., Levav, Kohn, Montoya et al., 2005).
Few studies have measured suicide
reduction directly (e.g., Rutz, von Knorring,
Rihmer et al., 1995). Most studies have
evaluated indirect gains such as changes
in the pragmatism of the professionals or
Reginato et al., 2007; Oordt, Jobes,
Fonseca et al., 2009).
This project aimed at improving
professionals’ skills in diagnosing and
treating mental disturbances that are cor-
related with suicide as early as possible
and at improving health professionals’
attitudes toward individuals with suicidal
behavior. The objective of this study
was to measure the impact of this training
in terms of changing the knowledge and
attitudes of the health teams toward
suicidal behavior.

384

METHODS
Setting and Subjects
Training in suicide prevention was
available for all 410 health professionals
with a higher education degree who worked
in the municipal public health network of
Campinas city, Brazil. Campinas is a city
of 1.2 million inhabitants located in the
most economically developed region of
Brazil.
The selection of participants for this
training was aimed at professionals who
were routinely involved with patients at
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high risk for suicide. Campinas is organized
in five health administration areas, com-
prising specialized mental health centers
and primary health care units. All the train-
ing seats were equally divided between the
health care services (60 for each area). Each
health team performed the selection of
candidates for the training; 270 profes-
sionals were chosen to participate.
Instruments and Measures
The Suicide Behavior Attitude Ques-
tionnaire (SBAQ) (Botega, Reginato, da
Silva et al., 2005) was used to measure
the attitudes of the participants. The SBAQ
consists of 21 statements followed by
self-filled analogical visual scales that mea-
sure the cognitive, affective, and behavioral
aspects of attitudes. Three SBAQ factorial
sub-scales were considered in the analysis:
suicide right (e.g., ‘‘Despite everything, I
think that if a person wants to kill him=
herself he=she has the right to’’); negative
feelings with regards to the patient with
suicidal behavior (e.g., ‘‘One feels impotent
towards a person that wants to kill him=
herself’’) and perception of professional
capacity to deal with patients (e.g., ‘‘I feel
capable of helping a person who attempted
suicide’’). Another four questions on
depression were added in the same format
as the SBAQ items.
ARCHIVES OF SUICIDE RESEARCH
C. F. da Silva Cais et al.
A Suicide Prevention Knowledge
Questionnaire (SPKQ) with 21 multiple-
choice questions was developed for this
project. Most of the questions (18) involved
clinical cases that represented the most
common situations experienced by health-
care professionals dealing with patients at
risk of suicide, such as depression and alco-
hol dependence. In relation to the thematic
areas, there were seven questions related to
depression and mood disorders, six on the
use of psychoactive substances (predomi-
nantly alcohol), three on epidemiologic
knowledge, two on psychic functioning of
an individual under suicide risk, and one
question for each of the following subjects:
suicide prevention strategy, suicide inten-
tionality, risk and protection factors, and
evaluation of suicide risk.
Procedures
Suicide prevention training consisted
of 18 hours divided into 14 hours of theor-
etical exposition and 4 hours of discussion,
during which the participants shared clini-
cal cases that they were conducting
(Table 1). They were motivated to present
their own attitudes and concerns in the
management of the clinical cases. The
training was repeated three times for three
groups from April to July of 2007. Both
the SBAQ and the Questionnaire on
Suicide Prevention Knowledge were con-
ducted at the beginning and the end of
training. The questionnaires were anony-
mously filled out over an average period
of 90 minutes.
Data Analysis
Each item of the SBAQ corresponds
to an analog visual scale of 10 cm varying
from total disagreement to total agreement
and scores from 0 to 10 for each item.
The scores of the three factorial
sub-scales varied between 0 to 30 points,
385
 Suicide Prevention Training in a Brazilian City

TABLE 1. Contents of Suicide Prevention Training

Suicide epidemiology: Changes in the global and Brazilian suicide rates for populational groups; data on
suicidal behavior of the Campinas city population.
General vision of suicidal behavior: Historic, religious, and social-cultural aspects; panorama of suicidal
theoretical approaches.
Health team attitudes: Attitude construct (beliefs, behavior, feelings); impact of the attitude of the health team
on patient care; myths and truths on suicidal behavior; meanings of the suicidal behavior (e.g., death desire,
asking for help, attempt to change the environment).
Mental disturbances and suicide: Multiple causalities of suicide; correlation between psychological pain and
suicide; psychiatric disorders and suicide; detection and adequate treatment of depression and alcohol use
disorders, bipolar disorder, schizophrenia, and personality disorders; impulsivity and suicidal behavior;
pharmacological and psychotherapeutic management.
Suicide risk evaluation: Steps in risk evaluation; evaluation of the suicide intentionality; short-term
management risk.
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Suicide prevention strategies: Levels of suicide prevention; prevention strategies recommended by the World
Health Organization; global evidence about suicide prevention; national programs of suicide prevention;
suicide prevention in Brazil.

as each had three items. For the factor
‘‘suicide right,’’ a higher score could mean
an attitude that is less ‘‘moralist=judicial.’’
For ‘‘negative feelings with regards to the
patient,’’ a higher score is related to a
higher presence of such feelings, which
can be an obstacle to helping individuals
with suicidal behavior. Regarding the ‘‘pro-
fessional capacity perception’’ factor, a
higher score could mean that professionals
are more confident in assisting individuals
with suicidal behavior.
For the knowledge questionnaire,
one point was added to the score for each
correct answer from a total of 21 multiple-
choice questions, making the total score
range between 0 and 21 points.
To evaluate the evolution of the
numerical variables between two times the
Wilcoxon test was used for the related sam-
ples, and the McNemar was used for categ-
orical variables. The level of significance
adopted for the statistical tests was 5%
(p < .05).
This project was submitted and
approved by a commission in research
ethics. The health professionals who were
trained and who agreed to answer the ques-
tionnaires signed a formal consent.
RESULTS
Of the 270 health professionals who parti-
cipated in the training, 230 (85.2%) agreed
to take part in the study. One hundred and
fifty nine individuals (58.9%) filled out the
knowledge questionnaire at the beginning
and at the end of the training. One hun-
dred thirty-five individuals (50%) filled
out the attitude questionnaire both times.
Table 2 presents the social-demographic
profile of the individualswho participated
in the training.
Changes in attitudes were observed in
18 SBAQ statements, for example, ‘‘it is
hard to differentiate if patients appear to
be unhappy or if they have depression that
needs to be treated’’ (p < .001), ‘‘Who gives
a forewarning usually does not kill oneself’’
(p < .001), ‘‘I am afraid of asking about
ideas of suicide, for fear of inducing it’’
(p < .001). Using ANOVA analysis, the
evolution of the three SBAQ sub-scales at

386 VOLUME 15
NUMBER 4
2011


TABLE 2. Social-demographical characteristics of the professionals who took part
in the training
Variables
Gender
Female
Male
Age groups
<30
30 to 40
>40
Occupations
Physicians
Psychologists
Occupational therapists
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Others (nurses, social workers, social
educators with a higher degree, etc.)
the beginning of the course (T1) and at the
end of the course (T2) were: negative feel-
ings in relation to patients with suicidal
behavior (T1 ¼ 8.9, T2 ¼ 7.1; p ¼ 0.002),
suicide right (T1 ¼ 14.8, T2 ¼ 16.1;
p ¼ 0.02), professional capacity perception
(T1 ¼ 15.6, T2 ¼ 21.5; p < 0.001).
The scores in the Knowledge Ques-
tionnaire Evolution of the health profes-
sionals’ knowledge who answered the
questionnaire at the beginning and the
end indicated that there is a statistically sig-
nificant increase between the two time
points (8.9 to 13, p < .001).
The changes detected by the Knowl-
edge Questionnaire were: improvement in
the management of depressive patients,
in the ability to evaluate suicide risk, in
epidemiological information about suicidal
behavior, in the diagnosis and manage-
ment of alcohol dependent individuals, in
the knowledge about efficient strategies
of suicide prevention, in the ability to
evaluate lethal intentionality in a suicide
attempt, in the knowledge of the genesis
of the suicidal behavior, and in the acute
mental functioning of the individual at
suicide risk.
ARCHIVES OF SUICIDE RESEARCH
C. F. da Silva Cais et al.
Frequency (N ¼ 270) Percentage (%)
229 84.8
41 15.2
63 23.3
107 39.6
100 37.1
57 21.1
69 25.6
43 15.9
101 37.4
The training led to improvement
in the knowledge and changes of atti-
tudes in all different occupations and
age groups, despite the differences
observed at the beginning. For example,
the younger professionals (age < 30 years)
arrived at the training with more knowl-
edge (9.49 vs. 7.88) than the older indivi-
duals (age > 40 years). By the end of the
training, the younger individuals still had
more knowledge (13.21 vs. 12.57) than
the older ones. Statistically, there was
no difference in the percent increase in
the knowledge of either group. The same
can be observed for all occupations. For
example, physicians arrived at the train-
ing with more knowledge than the psy-
chologists (10.51 vs. 9.45); at the end of
the training, the physicians still had more
knowledge (14.21 vs. 13.08), and there
was no statistical difference in the knowl-
edge increase.
DISCUSSION
The training led to favorable changes in
knowledge about suicide prevention and
387
 Suicide Prevention Training in a Brazilian City
in the attitude of the health professionals
assisting individuals with suicidal behavior.
As limitations of the study, we high-
light the following issues. Among the pro-
fessionals that were trained, only 58% and
50% answered the knowledge and attitude
questionnaires, respectively. In this study,
the changes were measured using question-
naires, which are indirect measures of
reality. Other studies, such as Rutz et al.
(1995), measured the alterations in the
pragmatism of the professionals who parti-
cipated in the training based on changes in
the prescription of anti-depressive and ben-
zodiazepines or changes in the number of
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psychiatric hospitalizations and amount of
work leave due to depression.
Another important limitation is the dif-
ficulty in comparing the results of the
present training in suicide prevention with
other similar preventive strategies. In the
medical literature on suicide prevention
methodology, there is no agreement with
respect to the training methodology, con-
tent selection and focus, or measurements
of the results, thus, allowing only a super-
ficial comparison. Most other training para-
digms also led to positive results in terms
of improvement of attitudes, clinical prac-
tices, or knowledge in suicide prevention
(e.g., Appleby, Morriss, Gask et al., 2000;
Botega, da Silva, Reginato et al., 2007;
Gask, Lever-Green, & Hays, 2008; Hegerl,
Althaus, Schmidtke et al., 2006; Morriss,
Gask, Webb et al., 2005; Oordt, Jobes,
Fonseca et al., 2009; Rutz, 2001; Rutz,
von Knorring, Pihlgren et al., 1995;
Simpson, Franke, & Gillett, 2007; Szanto,
Kalmar, Hendin et al., 2007; Tierney,
1994). Only a few training programs have
been reported to fail in the literature (e.g.,
Levav, Kohn, Montoya et al., 2005).
We must consider that the projects that
did not accomplish their goals seem less
likely to have been published. Of the pre-
viously mentioned trainings, two used
methodologies somewhat similar to those
in this project (Berlin, Perizzolo, Lejderman
388 VOLUME 15
NUMBER 4
2011
et al., 2007; Botega, da Silva, Reginato et al.,
2007). They were also carried out in Brazil,
with some similarity in the training content
and the use of the SBAQ to measure atti-
tude changes. However, comparison with
these studies remains difficult, as methodo-
logical differences widely outweigh the
similarities. Of these three training pro-
grams, the one in the present study showed
attitude changes about suicidal behavior in
the most dimensions of the attitude ques-
tionnaire (considering the significance level
of 95% for each item of the attitude ques-
tionnaire). We consider that the greater
extent of changes may be due to more
hours=classes in this training.
Several favorable changes occurred
in the attitude of the professionals who
took part in the training, for example,
perception of the professionals submitted
to the training to be more apt to distinguish
sadness=unhappiness from depression;
demystification of certain beliefs of high
prevalence that have a negative impact
in the suicide prevention, such as: depres-
sion refers to weakness or to an immut-
able characteristic of personality; someone
who threatens to kill himself will not
really do it; to ask about suicidal beha-
vior can induce the patient to commit
suicide.
The gains in knowledge about suicide
prevention as measured by the question-
naire are in a wide range of themes. This
knowledge, for example, the best moment
to suggest abstinence from a substance to
an addict, or the elements that determine
that an individual is at an acute risk of
suicide, greatly increases the ability of a
professional to prevent suicide.
It is expected that these changes in atti-
tude and knowledge directly affect the
pragmatism of the professionals. Although
we cannot confirm that such changes in
attitude or knowledge in suicide prevention
result in the reduction of suicides, we con-
sider it improbable that such changes in a
wide group of professionals who routinely

deal with individuals at suicide risk would
not affect the suicide rate.
We suggest the repetition of this
training, with the addition of direct mea-
surements of possible changes in the clinical
pragmatism of the professionals who
participated in the training, for example,
prescription of anti-depressive and benzo-
diazepines or changes in the number of
psychiatric hospitalizations, to provide
another type of validation of its efficiency.
AUTHOR NOTE
Downloaded by [64.66.26.185] at 13:37 03 June 2014
Carlos Filinto da Silva Cais, Isabel Ugarte
da Silveira, Sabrina Stefanello, and Neury
José Botega, Department of Medical
Psychology and Psychiatry, School of
Medical Sciences, Universidade Estadual
de Campinas, Campinas, Brazil.
Correspondence concerning this article
should be addressed to Carlos Filinto da
Silva Cais, Department of Medical Psy-
chology and Psychiatry, School of Medical
Sciences, Universidade Estadual de Campi-
nas, Rua MMDC 47, Campinas SP,
13025-130, Brazil. E-mail: carlosfscais@
yahoo.com.br
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