Prevention of non-suicidal self-injury: construction and validation of educational material

Abstract Objective: to develop and validate educational material to strengthen adolescent health care on non-suicidal self-injury. Method: methodological research designed in three stages: (1) construction of the material based on a mixed study on needs related to the theme through social networks and an umbrella review on health care related to non-suicidal self-injury; (2) validation with 10 experts in mental health and/or self-inflicted violence selected through the Lattes Platform; (3) evaluation by the target public, with health professionals being invited, without restriction of training. Validation and evaluation data were collected by using a sociodemographic questionnaire and the Suitability Assessment of Materials for evaluation of health-related information for adults. We used descriptive statistics, content validity index, and Gwet’s AC1 test. Results: the material obtained good general acceptance and reliability in the validation by the experts (AC1= 0.633; p=0.0000) and in the evaluation by the target public (AC1=0.716; p=0.0000). All professionals pointed out the personal contribution and educational potential of the material. Conclusion: we highlight the construction of science-based educational material to strengthen the health care for adolescents with non-suicidal self-injury.


Introduction
Non-suicidal self-injury (NSSI), popularly known as self-mutilation, is considered an intentional and self-directed behavior of aggression, without conscious intention of suicide and for reasons not accepted socially or culturally (1)(2)(3)(4) . It is a multifactorial behavior that affects, in particular, adolescents aged 11 to 13 years and has important emotional, physical and social repercussions, in the short and long term (5)(6) .
NSSI can have several functions or purposes and there is the possibility of coexistence of multiple functions (7)(8) . Intrapersonal functions (associated with managing or altering an internal state) are more frequent than interpersonal functions (related to communicating problems or influencing the external environment) (8) .
Such finding emphasizes the suffering related to the behavior and the importance of avoiding trivialization (7) .
Adolescents with NSSI report negative experiences such as misunderstanding, judgment and lack of empathy and credibility when seeking health care (9)(10) .
Health professionals also highlight the lack of formal training, governability and a feeling of unpreparedness to provide health care to adolescents with NSSI (11) . A Brazilian study conducted with health and education professionals observed the trivialization of NSSI, considered not relevant as a health issue (12) . Researchers also point out a restrictive care, without coordination in the follow-up, in addition to a superficial therapeutic approach and adherence problems (13)(14)(15) . Inadequate compulsory notification of cases of NSSI is also highlighted. The underreporting and incorrect completion of the intentionality of self-inflicted violence severely compromise the quality of the recording of this information (16) .
Studies point to the importance of investing in professional training and in the construction of guidelines that can guide the health care of adolescents with non-suicidal self-injury (11,17) . A Brazilian study with nursing undergraduates found the relation between reading educational materials and more positive attitudes about self-inflicted violence (18) . An Australian research highlighted education and training to improve professional knowledge and attitudes in Nursing, contributing to more positive results in the health care of adolescents who self-injure (19) .
In Brazil, the production of textual content on the behavior arises from 2018, most of which are educational booklets for the general public and addressing the behavior in the background. This study was based on the potential of the construction of textual material based on methodological research to support the education of health professionals for the enhancement of health care for adolescents with NSSI. Thus, the objective of this study was to develop and validate educational material to strengthen adolescent health care on non-suicidal self-injury.

Method
This is a methodological study for the construction of products with high methodological rigor, validated by experts and evaluated by the public for which it is intended (20) . This research meets the recommendations of the Consolidated criteria for Reporting Qualitative research (COREQ) and followed the steps described in Figure 1.

Validation Evaluation
Mixed study to survey needs through the characterization and understanding of posts on the subject on Twitter ® .
Umbrella Review (JBI) to trace health care for people with non-suicidal self-injury.
Validation with 10 experts on non-suicidal self-injury and training in mental health.
Evaluation with 30 health professionals and subsequent dissemination in social networks and institutional emails.

Construction of educational material
The educational material was built based on two scientific studies, the first being mixed (21)

Validation and evaluation of educational material
The experts participating in the study were selected through the Lattes Platform, in April 2021, by means of two distinct searches with the terms "non-suicidal self-injury" and "training in mental health" and nationality filter "Brazilian." The experts were selected according to the criteria of expertise (24) and should meet at least one of the following criteria: (1) (26) .
We also used Gwet's AC1 test, which measures the degree of agreement or the reliability of the agreement obtained between the evaluators. This test is robust, communicable, interpretable and not sensitive to marginal homogeneity, and it can be used with nominal and ordinal variables and with missing data (27) . To classify the reliability obtained, we adopted the following parameters: poor reliability (less than or equal to 0.20); fair (0.21 to 0.40); moderate (0.41 to 0.60); good (0.61 to 0.80) and very good (greater than 0.81) (27) .

Construction
The educational material "Non-suicidal self-injury: health care and mental health promotion" was composed of 58 pages, divided into pre-textual elements (cover, catalog Most items related to purpose, content, context, reading level, illustrations, motivation and self-efficacy were evaluated at 100% adequacy (CVI=1.0) ( Table 1).  The items on content and motivation showed very good reliability. The illustrations, layout and culture showed good reliability. And the item language presented a moderate reliability (Table 2). The main suggestions were related to three general themes: (1)   All items of the educational material reached the minimum approval criteria (CVI≥80%) in the evaluation by health professionals. All items reached validity of acceptance of health professionals above 90% (Table 3). Regarding the reliability of agreement, the educational material showed good reliability in the overall evaluation.

Evaluation by the target public
The items on language, illustrations and motivation showed good reliability. And the items on content, layout and culture showed very good reliability (Table 4).  In health care actions related to NSSI, it is essential to invest in the strengthening of protective factors, such as self-knowledge and assertive expression of needs, resilience, emotional regulation, self-esteem and self-efficacy, hope, healthy lifestyle, coping strategies, problem-solving skills, satisfactory interpersonal relationships, and support network (13)(14)(28)(29) .
It is noted that the material promotes expanded understanding of NSSI as a multifactorial phenomenon, which involves not only individual and relational factors, but also several social health determinants. Thus, we highlight the need to guarantee human rights and mental health (29) and to fight for decent living conditions and quality of life. Such aspects are particularly important in the current Brazilian conjuncture, with increased poverty, food insecurity (30) , school dropout rate (31) , easier access to lethal methods (32)(33) , social and environmental injustice (34) and disruption of social, health care and, especially, mental health programs (35) .
Despite the approval of a national policy geared toward the prevention of NSSI represents an advance (36)(37)(38) , for it to translate into favorable results, it is still necessary to consolidate public policies that subsidize conditions for a dignified life and access to quality mental health care.
Some ways to achieve these results are the commitment to human rights, social participation, expansion of access to mental health care services (39) , investment in science, and governmental commitment.
Another issue to be discussed is health training for NSSI-related prevention and care. In this study, most professionals highlighted the lack of formal training for provision of health care to adolescents with NSSI.
However, the participants stated that they had professional experience in the subject. Thus, it is necessary to expand and enhance the professional training and qualification for the prevention of NSSI. It is important to invest in the construction of new teaching-learning strategies, but also in the inclusion of this content in the curricula of health care-related programs.
In the process of constructing the material, the predominant use of international scientific literature is highlighted. There were gaps in the contextualization of NSSI in socially vulnerable groups (indigenous people, black people, LGBTQIA+, quilombolas, among others).
scientific research on the phenomenon in different contexts and social groups in Brazil.
The literature contains few indications of recommendations of NSSI-related health care that are associated with the virtual environment. It is necessary to conduct research on best practices and guidelines for health care actions that consider self-inflicted violence and the safe use of screens (40)(41) .
The educational material was disseminated via institutional e-mail to Universities, State Health Secretariats, governmental and non-governmental agencies. The content was also disseminated on social networks of the research group (@inspiracaoleps).
The study presents limitations related to the restriction of the validation process in the Southeast region. However, this study presents the first Brazilian educational material produced through methodological research with a focus on training for the prevention of NSSI. It is expected that the material will contribute to enhance interprofessional health care and raise new discussions, expanding perspectives and possibilities of health care for adolescents with NSSI.