Impact of "+Contigo" training on the knowledge and attitudes of health care professionals about suicide

OBJECTIVES: to evaluate the results of "+Contigo" training, developed by nurses and directed at 66 health professionals of integrated school health teams in Primary Health Care. METHOD: quantitative with data collection through the Suicide Behavior Attitude Questionnaire, administered before and after the training. RESULTS: significant increases were observed in suicide prevention knowledge and in changing attitudes of health professionals towards individuals with suicidal behavior. CONCLUSION: these results allow us to affirm that nurses hold scientific and pedagogical knowledge that grant them a privileged position in the health teams, to develop training aimed at health professionals involved in suicide prevention.


Introduction
Suicide is a complex, multifaceted, underestimated and often avoidable phenomenon. In Portugal, about 1000 suicides are committed per year, with an upward trend since the year 2000. In the central region, suicide rates have slightly increased in recent years (11.2/100,000, in 2009), superior to the national rate (9.5) for the same period. A higher incidence level is found in the South of Santarém and suicide is characterized as a phenomenon mainly of elderly people. Parasuicidal behaviors, however, mainly involve young people, with a uniform distribution at the national level.
Scientific evidence proves that suicide is significantly associated with mental illness, based on which it can be affirmed that an effective treatment of mental illness increases the probability of reducing suicide risks. For this treatment to be effective, however, the correct and timely identification of the individuals at risk and the elimination of access barriers to specialized care are fundamental. These barriers include, among others, the stigma of mental illness that still exists, even among health professionals, and the lack of investments in health professionals' education (1) .
The interpretation of suicidal behaviors by health professionals is very important to determine their actions involving these individuals, concerning hospital care and forwarding (2) . In that sense, countless studies have focused on the prevalent attitudes of health professionals towards people with suicidal behaviors, suggesting that negative attitudes, criticism and devaluation are predominant among these professionals (3)(4)(5)(6)(7) .
Feelings like anxiety and insecurity, fear, excessive involvement, sympathy, irritation and anger also prevail (8) . Knowledge on the phenomenon is one of the variables studies, about which a relative consensus exists that it is insufficient (4)(5) .
The comparison between health professionals' attitudes towards people with suicidal behaviors and people with physical illness shows the professionals' hostile attitudes towards the former (9) .
As to the differences found in the health professionals' attitudes per professional category, physicians generally show more negative attitudes than nurses (10) . Psychiatrists stand out because their attitudes are more positive than of physicians in other specialties (11) . In a study developed in the United Kingdom, however, the physicians were more aware of the suicide risk than the nurses (4) .
Parallel to these orientations are the results obtained in educational interventions, which are mostly stimulating, as verified in the literature. Based on the analysis of these results, it can be concluded that educational interventions are effective to improve knowledge, change attitudes and improve the health professionals' competency levels to prevent suicide (3)(4)7,19) . These effects were mostly assessed in the short term and no differences were verified between general and psychiatric hospitals (3,11,13,20) . with the problem, the lack of support from expert professionals and the absence of guidelines for good practices as barriers (16) .  (21) .
The question about how long the changes in the professionals' behavior towards people with suicidal behaviors will continue remains unanswered.
Based on these considerations and in the context of the Suicide Prevention Project in the School Context "+Contigo", designed and implemented by the authors of this paper, which recommends the participation of all stakeholders in the school context, training courses were developed for Primary Healthcare professionals.

Method
A quasi-experimental study without a control group was developed, with the following objectives: -to assess the results of training directed at Primary Healthcare professionals; -to verify whether knowledge and attitude differences exist with regard to suicidal behavior in function of the variables age, gender, experience and function.
The impact of the training is assessed through the analysis of the following aspects: attitudes towards the depressed patient, negative feelings towards individuals with suicidal behavior, perceived professional skills, right to suicide and knowledge in suicide prevention (2) .
The training was offered during three courses of 21 hours each, aimed at Primary Healthcare professionals and more specifically school health team professionals.  should be highlighted that the only factor in which no increase was found between the mean scores on the initial assessment "before the course" and the final assessment "after the course" was factor 3, called the right to suicide.

Sixty-six
Based on the statistical analysis, it can be added that no statistically significant differences were verified in the attitudes towards suicidal behavior in function of the variables gender, function performed, age and length of experience.

Discussion
The non-probabilistic sampling method is considered a methodological limitation, as the inclusion criteria, like the participation in the school health team and the personal and team motivation conditioned to the selection of an intentional sample. This type of sampling seemed inevitable, given the need to prepare these professionals to constitute the local "+Contigo" team and to be able to implement the Suicide Prevention Project in the School Context "+Contigo".
Another methodological limitation is the absence of a control group and of follow-up. These were conscious options, keeping in mind that all health professionals who attended the training course "+Contigo" adhered to the project and, consequently, closely articulated with and were followed by the regional "+Contigo" team. This fact can interfere in the training impact and the longterm assessment. These options were based on studies that concluded that skills development after training is statistically significant in comparison with the control group and that the competences are mostly maintained six months after the training (3,5,11) .
Concerning the discussion of the results found, it can be affirmed that, at the level of the Suicide Behavior Attitude Questionnaire, an increase was verified in the mean scores for 22 out of 25 questionnaire items, with statistically significant differences in nine items. The analysis of these items grouped per factors showed higher mean scores in four of these factors and statistically significant differences in three.
The comparison between the results obtained in our study with those of another study (22) in which the Suicide Behavior Attitude Questionnaire was also used showed a significant variation after the training in 18 out of 25 questionnaire items used. These authors also concluded that the nurses express greater professional skills after the training (19) .
Some studies showed a 44% increase in acceptable levels when compared to the pre-training levels (23) , higher than the levels found in this study, which showed a global increase by 10.4% in the total number of items in the Suicide Behavior Attitude Questionnaire.
In a study of the professional skills of elements in the educative community, in the school context, it was verified that, after receiving gatekeeper training, these professionals referred less students to specialized monitoring or mental health services when compared to the professionals who did not receive gatekeeper training (23) . Team training increased the proportion of people who intervened in people with suicide risks by 20%.
According to our results, it has been concluded earlier that programs for community members demonstrated positive changes in the knowledge and attitudes towards suicide (23) . More specifically regarding the professionals' attitudes and using an attitude inventory before and after formal training, a reduction was found in the biased or negative attitudes expressed (3)(4) and significant improvements in the participants' attitudes and confidence (14) .
Furthermore, in the impact analysis of a brief intervention program on suicide prevention and health professionals' attitudes towards suicide, it was conclude that the brief training was determinant to provide the health professionals with knowledge about suicide prevention, independently of their clinical experience, allowing them to improve their short-term attitudes and beliefs on suicidal behaviors (24) .
The analysis of the mean scores obtained for the factors under investigation showed that the "right to suicide" was the only factor that did not show a higher mean score, with two assertions whose means dropped from 2.00 and 4.50 (before the training course) to In the analysis of this matter, it was concluded that the belief that a person is not entitled to commit suicide was stronger among older professionals, professionals who did not have contact with people with suicidal behaviors, professionals with a family history of suicide, protestant professionals and those who used to attend more religious services (24) .  (17,24) . In most of the studies analyzed, physicians generally present more negative attitudes than nurses (10) . The reason why this was not verified may be due to the small number of non-nurses.