Suicide is a growing global concern, with almost 1 million people died from suicide annually. Previous data reported that in every 1–2 s, one individual would have attempted suicide, and in every 20 s, one of the attempts would have been successful. Developing nations such as Malaysia is no exception from this burgeoning issue. The annual suicide rate in Malaysia was approximately 12/100,000 population, which commensurate to the global annual rate of 16 per 100,000. The suicide rate in Malaysia has increased by 60% over the past 45 years, leading to a steady increase of hospital admissions for attempted suicides and deaths. The World Health Organization (2012) revealed the alarming data of suicide incidence even among younger age groups, quoting suicide as the second leading cause of death among the 15–29 years old.
Unfortunately, due to various cultural, religious, and legal prohibitions, suicides are grossly underreported. Sixty-four percent of people who attempted suicide would have visited a doctor in the month before the attempt, while 38% of them have consulted a doctor within the week before the attempt. Despite that, due to suicide being a taboo deeply rooted in many cultures, patients may not actively volunteer their death wish as the main presenting symptom. According to the American Psychiatric Association (2018), some warning signs of suicide include a change in behavior, disrupted eating or sleep pattern, feeling of hopelessness, and talking about dying. Some of these symptoms may appear vague and nonspecific.
Health-care professionals deliver preventive, curative, and rehabilitative health-care services to the community and are generally classified under major group 2 by the International Standard Classification of Occupations. This includes medical doctors, nurses or midwifery professionals, traditional and complementary medicine practitioners, medical assistants, and veterinarians. Hence, breaking the stigma of suicidal attempts among the health-care professionals is fundamental, as it is a strong hindrance for potential victims to reach out for help.
As for those who had sufficient insight and courage to seek help for their suicidal ideation, the attitude of the health-care professionals who are in contact with them is crucial as it will affect the care and treatment provided. Therefore, assessing the health-care professionals’ attitude toward suicidal patients is paramount to ensure prompt and adequate management of these highly vulnerable cases. The previous qualitative study performed in Klang Valley among 32 health-care workers on their perception of patients’ suicidal intention and their understanding of factors leading to specific interpretations revealed that they had insufficient knowledge on suicide management and generally held negative attitudes toward suicidal patients. Similar observation was also seen among 264 Korean community mental health professionals and 228 hospital workers. These suggest that the attitude toward suicidal patients among health-care professionals is still poorly advocated, with recent papers recommended the institution of suicide training to be part of health-care curriculum to shape their positive behaviors in better management of suicidal cases in clinical practice.
Despite health-care professionals’ attitude being an important determinant to the outcome of clinical practice, there is a paucity of local data with regards to the attitude of health-care workers toward suicidal behavior, as evidenced by the dearth of literature on this topic. Therefore, our study aimed to remedy this by evaluating the attitude of health-care professionals toward suicide and the factors associated with poor attitudes toward suicide.
This cross-sectional study was conducted among health-care professionals, including the medical doctors, nurses, and assistant medical officers. Other health-care professionals such as the dentists and pharmacists who were categorized under “other health-care professionals” by the International Standard Classification of Occupations, were excluded from this study.
The study was conducted in a single, public health-care facility in northwest Malaysia from January 1, 2019, to May 30, 2019.
Validated modified Suicide Opinion Questionnaire was used in this study to assess the respondents’ attitude toward suicidal behavior. The previous study has confirmed its validity and reliability (Cronbach’s alpha: 0.72).
The questionnaire contained 22 items, scored using a 5-point Likert scale. The possible responses range from “Strongly agree,” “Agree,” “Undecided,” “Disagree,” and “Strongly disagree.” Positively worded statements’ (item 1, item 3–8, and item 10–21) scores were set such that “Strongly agree” were scored as five and “Strongly disagree” as one. Negatively worded statements (item 2, item 9, and item 22) were scored in reverse. Therefore, the questionnaire had a possible range of total score of 22–110, which was later converted into percentage. A cutoff score was set at 80%, where a score of more than or equal to 80% reflected a positive attitude toward suicide according to Bloom’s cutoff point.
The 22 items were further divided into five sections including the acceptability of suicide (items 1–5), morality and mental illness (items 6–10), professional role, work, and care (items 11–15), communication and attention (items 16–18), and beliefs (items 19–22).
Eligible participants were identified through various clinical wards and units. A briefing session explaining about the study objectives and mode of conduct was delivered and all eligible participants were invited to join the study. A copy of the participant information sheet was distributed to those who wished to participate, and the informed consent form was signed before the questionnaire was distributed. Each participant was given around 30 min to answer the questionnaire. Any queries regarding any of the items in the questionnaire were clarified by the member of the study team present at the site. The questionnaire was then collected, and data were manually entered into an Excel programming software by two study personnel, one acted to verify the data entered.
Sample size estimation was calculated using single means formulae. Prior data indicated the mean attitude score toward suicide was 74.97 ± 5.15 among nurses. Thus, a minimum sample size of 239 samples was needed to be able to reject the null hypothesis with 80% power and type I error probability of 0.05. Therefore, with an additional of 20% dropout rate, the minimum sample size required was 299 samples.
Data collected were analyzed using Statistical Package of the Social Sciences (SPSS) version 26 (IBM, New York, USA). Descriptive statistics using frequency and percentages were used to describe the sociodemographic background of the study respondents. Simple logistic regression was used to determine the associated factors to poor attitude toward suicide, whereas multivariable logistic regression was used to determine the association of selected variables to poor attitude toward suicidal behavior. Variables with the P < 0.25 from the simple logistic regression were selected for multivariable logistic regression modeling. A P < 0.05 was taken as the cutoff point of statistical significance.
The study was conducted in compliance with the Declaration of Helsinki 1964. Ethical clearance was obtained from the Medical Research and Ethics Review Committee of the Ministry of Health Malaysia (NMRR-17-3241-39439).
A total of 530 health-care professionals were approached during the briefing session, and 487 (91.9% response rate) consented to participate. Respondents were mostly between 20 and 29 years old (n = 199, 40.9%) with a median age of 31.0 years old (interquartile range = 11.00). Majority of the respondents were females (n = 347, 71.3%) and most of them were Muslims (n = 439, 91.3%). Most respondents had diploma as the highest education level (n = 293, 60.2%). Up to 90% of the study respondents were from major clinical departments (n = 436, 89.5%), with nurses contributing to the majority of respondents (n = 250, 51.3%). Many of them have had working experience for more than 10 years (n = 161, 33.1%), yet the majority (n = 331, 69.0%) had never attended any suicide-related awareness courses [Table 1].
Overall, majority of the study respondents held a negative attitude toward suicide (n = 345) and were found to score the lowest in the “Communication and attention” section. On the other hand, the highest scores were determined from the “Professional role, work, and care” section [Table 2]. Table 3 further describes the numerical scoring for attitude toward suicide according to the profession, whereby the nurses were found to score the least in the overall section.In addition, three variables were significantly associated with attitude toward suicidal behavior, namely religion (P = 0.027), education level (P = 0.007), and occupation (P = 0.007). Multivariate logistic regression using enter method showed that occupation is the only significant factor associated with negative attitude score (P = 0.034), whereby medical doctors were found to be 2.1 times more likely to score poorer as compared to nurses [Table 4].
This study aimed to assess the attitude of doctors, nurses, and assistant medical officers toward suicidal behavior. To improve the willingness of health-care professionals to engage with cases of suicidal behavior, the key factor is to explore the factors influencing their judgment toward those who presented with self-harm, and attitude is one of them.
Our study found that health-care professionals displayed a relatively unfavorable attitude toward cases of attempted suicide. Our findings resonated with several published review articles which found that the attitude of hospital staff toward people who engaged in self-harm was mostly expressed with negative attitudes, feelings of irritation, and anger. They were also described to be less optimistic, reported less willingness to help, and expressed higher levels of irritation. This could have been contributed by the lack of knowledge and understanding on issues surrounding suicidal attempts.
Our respondents scored the lowest in the “Communication and attention” section of the questionnaire, as compared to the “Acceptability,” “Morality and mental illness,” “Professional role, work, and care,” and “Beliefs” sections. This inferred that in general, respondents had a better attitude when trying to explore the acceptability, morality, and beliefs surrounding suicide. They were also positive in acknowledging their professional role to assist this group of patients. Nonetheless, communication was evident as the weakest point as many of them failed to look at suicidal attempts as a patient’s cry for help in a positive light. Doyle et al. has shown that only a minority consider “empathy” and “understanding” as being important when caring for patients with suicidal behavior.
Most of the religions worldwide viewed suicide as one of the greatest sins to the extent of being a major taboo and a highly stigmatized topic. This echoed in our study, where the majority of the respondents had unfavorable attitudes toward suicidal behavior. Therefore, there is a necessity for additional emotional and mental health support for those who have attempted suicide. To the best of our knowledge, there was no specific study that has elaborated on the association between different types of religions and attitudes toward suicide as exemplified in our study.
The level of education was significantly associated with attitude toward suicide. In our study, advanced degree holders (i.e., degree and Masters) appeared to hold poorer attitudes toward suicide as compared to those with diploma holders. This was an unprecedented finding as Gibb et al. were unable to establish any association between the level of education and attitude toward suicide, while another study found that doctors across various education levels appeared to be equivalent in terms of their attitude toward patients with borderline personality disorders who harmed themselves. Such observation of cognitive and judgmental biases among advanced degree holders in our study could have been contributed by a lack of empathy and ability to distinguish between the objective-factual aspects of the decision and the subjective aspects. Education does not by nature improves moral development, rather it involves a complex interplay of psychological and environmental factors. Furthermore, highly qualified people may lack social skills as they may overthink responses, find it tough to find common ground with people, too self-conscious and egocentric, and tend to hide their vulnerabilities. However, it is worth noting that majority of our respondents who attained diploma level were nurses, implying a likely association between occupation and attitude level.
Occupation was the only significant factor toward poor attitude toward suicidal behavior. We found that the medical doctors held unfavorable attitudes toward suicide as compared to nurses. This echoed in a study among 400 medical doctors, nurses, and social workers on the possible biases in suicide risk perception, which found that the bias was more pronounced among doctors and in male respondents. Our proposed reason behind this trend was that nurses typically spend more time with the patients, hence would have had more opportunities to learn about their patients’ suicidal drives, thereby fostering the recognition behind such actions. Furthermore, medical doctors tend to work long hours and the accompanying physical and mental exhaustion may link to the negative attitude toward people presented with self-harm. Therefore, despite many previous studies demonstrating the benevolence and selfless attitude generally held by the medical practitioners, our study proved otherwise. This was indeed a major cause for concern and warrant further studies to look at the factors contributing to such attitude.
We suggest that the lack of suicide-specific training may contribute to the generally negative attitudes held toward suicidal behavior. Overall, our respondents scored the lowest in the “Communication and attention” section, insinuating poor appreciation for the message behind suicide attempts as a mean of communication and a cry for help.
Therefore, workshops on suicide awareness should be regularly conducted as part of clinical training across various professions in health care, and should attempt to incorporate training on communication skills, and allow participants to train with simulated patients to foster better understanding and compassion when dealing with actual cases of self-harm and suicidal behavior.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
The authors would like to thank the Directorate General of Health Malaysia for his permission to publish this article. We are also grateful to Dr. Karniza Khalid from Clinical Research Centre, Hospital Tuanku Fauziah, Perlis, Malaysia, for her technical assistance.
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