INTRODUCTION

Suicide among adolescents is an urgent public health challenge in Brazil since there has been a significant increase in suicide attempts and deaths (Ministry of Health, 2021). This phenomenon not only impacts the lives of young people, but also their communities (WHO, 2023).

Suicidal behavior comprises a continuum encompassing all aspects related to the act of taking one’s own life (Bertolote, 2012). It includes suicide, characterized by the act of taking one’s own life; attempted suicide, a non-fatal, self-inflicted action, with the aim of achieving death; and suicidal ideation, involving thoughts and planning related to suicide (Klonsky et al., 2016).

Adolescence is a key stage in human development, since this is the period when an individual acquires the knowledge and skills to deal with social and emotional issues to actively contribute to social life (WHO, 2020). It is a period when suicidal thoughts are common in the situations of acute stress adolescents face, but they are usually fleeting and do not necessarily constitute psychopathology. However, if these thoughts are persistent and intense, the risk of suicidal behavior increases. Adolescents are more prone to impulsivity and immediacy, as their emotional health is rapidly developing, so the end of a relationship, a situation of humiliation or not belonging to a group can trigger suicidal behavior (Botega, 2015).

Low self-esteem, limited problem-solving ability, anxiety, a previous mental disorder, sexual abuse, physical violence, psychological violence, childhood abuse, loss of significant others, bullying, a history of suicide attempts, suicidal ideation, non-suicidal self-injury, lack of family or social support, feelings of hopelessness, helplessness, pessimism, impaired school performance, perfectionism, use of psychoactive substances and access to lethal means can all promote suicidal behavior (Santos et al., 2014; Dávila Cervantes & Luna Contreras, 2019). It has been estimated that 90% of suicide cases among young people are associated with depression (Hawton & Fortune, 2008; Hawton et al., 2012). For Bertolote et al., (2012) and Botega, (2015), risk factors related to mental disorders or individual and family history, as well as drafting a detailed suicide plan and previous suicide attempts increase suicide risk.

According to the World Health Organization, (2023), suicide mortality is a significant concern among young people ages 15 to 29. Every year, over 700,000 people commit suicide, with more than 20 suicide attempts for every act completed (WHO, 2023).

In the Americas, the suicide rate is 9.8 per 100,000 population, and is more prevalent among males (WHO, 2016). In Brazil, the rate is 6.6 per 100,000 population, and also more common among males. The past decade has seen an alarming 43% increase in the annual number of deaths by suicide in Brazil. This increase in cases was identified in every region in Brazil, with the South and Midwest having the highest suicide death rates. In terms of age group, there was an 81% increase in suicide death rates among adolescents. The North had the highest risk of death by suicide among young people ages 15 to 19, followed by the Midwest and the South (Ministry of Health, 2021). It is worth noting that the underreporting of cases of death by self-injury without intention to die may affect the data mentioned above (Avanci et al., 2021).

The worrying increase in suicide death rates in Brazil has led to a breakthrough in public policy. In 2019, the enactment of Law No. 13,819 established suicide prevention as a national policy, requiring the participation of all spheres of government. The legislation outlines several objectives for suicide prevention in the country, including the promotion of mental health, the control of factors that determine and condition mental health, as well as intersectoral coordination for suicide prevention, involving sectors such as education, health, social assistance and the press.

Despite the progress achieved in the legislative sector on the issue, where public policies are concerned, there is still a need to structure actions nationwide, particularly in the school environment, with a focus on mental health promotion and suicide prevention. In the Brazilian setting, the rise of suicidal behavior among teenage students contrasts with the incipient presence of public policies targeting schools to address this situation. There is a dearth of studies on the subject in the national context, showing that school staff often lack the knowledge to make referrals and conduct suicide prevention interventions. As a result, staff often feel ill-equipped to deal with situations involving suicidal behavior, reflecting the lack of research on this issue (Brito et al., 2020).

As teachers are in contact with adolescents on a daily basis in the school environment (Estanislau & Bressan, 2014), it is essential to explore how they have addressed suicidal behavior among adolescent students.

The aim of this study is therefore to understand how education professionals view the role of schools in addressing suicidal behavior.

METHOD

This is a transversal, exploratory, qualitative study using Vygotsky’s historical-cultural theoretical framework. The approach, based on dialectical and historical materialism, seeks to examine the relationship between phenomena, to explore rather than just describe, and to analyze historically constructed phenomena (Vygotsky, 2009). The qualitative aspect to examine the topic in greater depth is also used in the study of the history of relationships, opinions and interpretations (Polit et al., 2004; Minayo, 2013).

This article is an excerpt from the thesis entitled “Suicidal Behavior of Schoolchildren from the Perspective of Teachers and Nurses: a Study based on the Historical-Cultural Approach.”

Procedure and participants

Participants in this research were selected using the snowball method (Vinuto, 2014) because of lockdown during the COVID-19 pandemic, in which face-to-face contacts for research were suspended (Ornell et al., 2020). The invitation to participate in the survey was sent through social media to reach the largest possible number of potential participants.

The period for inviting participants and conducting interviews was October 1, 2020 to May 13, 2021.

The inclusion criterion was having worked as a teacher for at least a year at elementary and high schools in the state of São Paulo. The exclusion criterion was having been retired for over two years.

The study was conducted in the state of São Paulo due to the rise in suicide rates in the 10-19 age group, with an increase in deaths being observed from 113 in 2010 to 187 in 2019 in a population of 5,691,113 inhabitants (São Paulo, 2019).

Data ProductionTechnique

The technique used to produce data was an online questionnaire with questions on the characterization of the participants followed by the scheduling of a semi-structured remote interview.

For the semi-structured interview, the authors used an interview guide drawn up by the authors, based on a literature review conducted earlier, such as how long they had been working with adolescents, the support offered by the school for adolescents with suicidal behavior, and the role of teachers and school management in helping students with suicidal behavior. This type of interview was chosen because it is an expanded form of interaction that emerges at the time of data collection. The interview is regarded as a process of social interaction, both verbal and non-verbal, which takes place between the researcher, who has a specific aim, and an interviewee, who possesses relevant information for understanding the phenomenon being studied. This process is mainly mediated through language. During the interaction between the participants and the lead researcher, key information emerged that had not been included in the questions asked and was regarded as a useful contribution to the data. Another situation was the issues inherent in the spontaneous interaction during the interview, which enhanced the material used to construct the data (Manzini, 2004). These interactions during the interview proved to be an efficient means of understanding the phenomenon as a whole (Castro & Oliveira, 2022).

Initial contact with the professionals was made by the first author, a doctoral student nurse, specializing in mental health and psychiatry and suicidal behavior, with experience in this type of research. When interest in participating in the study was identified by telephone, Whatsapp messages, email or other forms of contact, a link was sent by email or Whatsapp to a form available on Google Forms with an Informed Consent Form. If the person agreed to take part in the study, they were directed to a page with questions about their personal details.

The invitation to take part in the survey was sent to twenty-one professionals using the snowball method. Although fourteen respondents agreed to take part in the survey, six of them did not schedule an appointment for the interview, leaving a total number of eight respondents. It was a challenge for teachers to take part. Some of the reasons given for declining to participate included being overworked as a result of the shift to remote teaching during the pandemic and difficulty securing an appointment for the interview. In addition, the researchers believe that the fact that this is a delicate subject to be approached online with an unknown person may have contributed to the reluctance to take part.

Interviews were conducted remotely by the first author, due to the COVID-19 restrictions, using Google Meet. The researcher began by introducing herself to each participant and subsequently proceeded to interview them. The pilot study was the first interview, in which the semi-structured interview guide was found to be adequate. As there is no indication in the historical-cultural approach to exclude an interview from a pilot study and as the interview guide was considered adequate, the interview was included in the data set.

The interviews were transcribed literally and accurately, preserving the participant’s speech and respecting the interviewees’ pauses. The total duration of the interviews was six hours, 13 minutes and 28 seconds.

Data construction tool

The method used was inductive thematic analysis, developed by Braun & Clarke, (2006), to identify relevant themes in the data. This type of analysis is compatible with Vygotsky’s, (2009) historical-cultural perspective, which provides an in-depth, theoretical understanding of the data collected, in line with the health promotion and mental health references used in this article.

Data were constructed by transcribing the interviews, yielding 149 single-spaced pages, formatted in Arial font, size 12. webQDA software was used to organize the codes generated inductively by the main researcher after a detailed reading of the interviews (Souza et al., 2016). The second researcher and the Health in Basic Education and Historical-Cultural Approach Research Group helped prepare the codes. To ensure the methodological rigor of this study, the Consolidated Criteria for Reporting Qualitative Research (COREQ) Checklist was used (Tong et al., 2007).

Characterization of Participants

Names of popular Brazilian singers were used as pseudonyms for the eight teachers who took part in the study. Below is a description of the participants at the time of the interview:

• Adriana, 33, holds a degree in Social Sciences, has worked as a teacher for three years and, at the time of the interview, had been a public-school coordinator for less than a year. She has been working with adolescents for eight years, has no specialization, has undergone psychotherapy, has not taken any courses or specializations related to suicide prevention, and has experienced situations related to the suicide of schoolchildren.

• Alceu, 39, holds a language degree, works at elementary and high schools, has worked with adolescents for nine years, and at public schools for ten, has been in therapy and has not experienced a situation with a student displaying suicidal behavior.

• Alcione, 47, holds a degree in physical education and pedagogy with a specialization in school management. She has worked as a teacher for 15 years at elementary and high schools and has had the same amount of experience with adolescents. She is currently deputy principal of a public school, has not been to therapy, has experienced situations of suicidal behavior among schoolchildren and has taken a suicide prevention course at a religious institution.

• Clara, 39, holds a graduate degree, works at elementary and high schools, and has worked with adolescents for five years, three in the public sector. She has already been to therapy, has no training in suicide prevention and has not experienced a situation involving suicidal behavior by adolescents at school.

• Elza, 32, is studying for a master’s degree, works in secondary education and has been professionally employed for ten years. She has worked with adolescents for 12 years, in the public sector for three years, has been in therapy and has experienced suicidal behavior among school adolescents.

• João, 23, holds a degree in physics, works in elementary and high schools, has been working with teenagers for two years, works at two schools, has never undergone psychological treatment, has not taken any courses related to suicide prevention and has experienced students at school who were at risk of taking their own lives.

• Marisa, 54, holds a degree in literature, works in elementary and high schools, has been working with adolescents for two years, has undergone therapy, and has not experienced situations involving suicidal behavior in school.

• Nara, 59, who does not provide details about her education, has worked at schools for 29 years, has 20 years of experience working with adolescents in elementary and high schools, and has worked in the public sector for 15 years. She currently works at a school, has not undergone therapy, has no training in suicide prevention and has not experienced situations involving suicidal behavior in schoolchildren.

Ethical considerations

This study was submitted to the Research Ethics Committee and complied with the norms and guidelines governing research with human beings, in accordance with Resolution 466/12 of the Ministry of Health. The study was submitted to the Research Ethics Committee of the Ribeirão Preto School of Nursing at the University of São Paulo (USP).

The data production period began after the study was approved by the Research Ethics Committee. Participation of the research subjects was contingent on their signing the Informed Consent Form. It is understood that this research offered subjective risks for its participants, such as the possibility of feeling uncomfortable with the content of the questions; feeling uncomfortable about giving answers, which are related to the processes in their everyday work; and difficulty answering the questionnaire during working hours. It was thought that one of the benefits of taking part in the study was that participants would have a space to express themselves and reflect on the mental health demands that have arisen in schools, with a researcher who is a registered nurse specializing in mental health and psychiatry. In addition, the results of the study will serve to spark discussions on public policies and practices in education and health services, which, in turn, would positively influence the actions taken with teenage students.

RESULTS AND DISCUSSION

The transcription of the eight interviews yielded 108 codes on the role of schools in suicidal behavior, from which the topic “Schools also involve the issue of affection between teachers and students” was constructed. The ten most frequent codes are given below: “Schools lack health services,” “Public schools have no interest in working with teachers on mental health,” “Schools as a welcoming environment,” “Schools as a social relations environment,” “School management of care for adolescents in distress when this affects other students,” “Training school staff to deal with students in distress,” “Public schools are not interested in working with professionals on suicide prevention,” “School and health services are separate when it comes to caring for adolescents,” “Schools work with specific actions regarding suicidal behavior,” “Schools are reluctant to address the issue.” The researchers preserved the words and expressions used by the participants when constructing the codes.

Elza says that schools are a place where affection is created between students and teachers, where there is genuine concern for these students on the part of teachers, who often provide support in students’ lives:

And schools also involve affection between teachers and students, don’t they? There is affection and this affection is shown in some way, you don’t need to touch the student or anything to show affection and show you care. Many public-school students used to have support from their teachers, a teacher who was their teacher friend, and now they don’t have that any more, do they? (Elza, teacher, 12 years’ experience)

In this extract, Elza describes the school environment as a space that goes beyond the realm of scientific knowledge, highlighting its importance in creating affection and bonds that can play a key role in protecting students from suicidal behavior.

Vygotsky (2009) emphasizes the importance of school for the individual, particularly during adolescence, because it is through mediated social relationships that adolescents construct their inner and outer worlds. At school, if social relationships are healthy and promote the achievement of life projects, it becomes a protective environment against suicidal behavior (Juliano & Yunes, 2014), with the education professional being the main subject in this process. But for effective care, there must be mediators in the school who encourage life. Studies by Brito et al., (2020), Santos et al., (2014) and Estanislau & Bressan, (2014) have shown the importance of training teachers so that schools can provide a healthy environment for students.

Elza also said that the support the school provided for students was related to the profile of the school management:

I don’t know if I was very unlucky, in fact, there was a school, the first school I went to in my life, a public school I went to work at, where the coordinator was very nice and cared about everyone. But at that school I didn’t have anything related to mental health to report. Now at the other schools, I’m just thinking about this, you know when you go over it in your mind just to be sure? But I can’t remember feeling any support for teachers or pupils at these public schools, it was all a bit unstructured in that respect. (Elza, teacher, 12 years’ experience)

Nara reports a lack of interest on the part of the school management in working with the mental health of students, saying that this is far from happening.

“But that’s a dream, isn’t it? Because public schools aren’t interested [in working with mental health].” (Nara, teacher, 20 years’ experience)

Alceu says that suicidal behavior is addressed in schools when an action has repercussions on other students; there is no individual focus on a student’s emotional suffering:

I think there’s this thing about paying attention, perhaps when it becomes more obvious. That at least we are beginning to realize that there are some conversations, some comments, and then the subject can even be put on the agenda. Not because the person who was in that situation [suicidal behavior] was looked at, but because their situation had repercussions for others, with those around them, and then the subject could end up on the agenda. (Alceu, teacher, 9 years’ experience)

In Alceu’s words, schools take care of students experiencing emotional distress to ensure that there are no repercussions for other students, rather than regarding them as a person in need of care. There is a fear about addressing suicide at school. The Statute of the Child and Adolescent (Child and Adolescent Statute, 1990) provides for comprehensive care for children and adolescents, with each individual representing a unique universe that requires a careful examination of their needs. Failure to care for an adolescent in emotional distress due to a lack of knowledge on the part of school management increases stigma, hampering care in these cases (Botega, 2015; Santos et al., 2014).

Marisa admits that it is difficult to work with students in the yellow September initiative because of the set activities, which disregard the fact that each school has its own routine, groups of students and needs. She says that the criteria used are quantitative, rather than what the student has understood as a result of the actions implemented:

[the Yellow September activities]¹ come from the top down, without a study of what’s happening here, because each school has its own personality, each school has its own routine, its own public, what’s good for one is not good for all of them. And we experience this situation a lot, having to treat everyone as though they were the same, you know? I think this ends up creating this issue that I find myself, again, thinking about what I said a little earlier, that quantitative criteria are often considered. So there’s this thing, a certain number of evaluations have to be submitted within this timeframe, and then there’s that demand, that rush, so that these evaluations can be done and then the results tabulated, without taking into account, as we said, actions that can be incorporated into the school’s routine and that, in fact, give meaning to what the student is experiencing there. So I think that sometimes the issue of quantity takes precedence, it weighs on us when it comes to dealing with mental health, and suicide prevention, because I imagine that it’s also something that requires a purpose, let’s say, or a way of thinking that can’t be one-sided, that can’t be something like.... You know? “This is the model and this is how it’s going to be,” you have to consider that you also need to pay attention to the feedback that the student is going to give you, so that you can also understand the moment they are going through. (Marisa, teacher, two years’ experience)

Marisa points out that school management focuses its attention on quantitative data in the Yellow September actions to meet the requirements of the Department of Education. These actions fail to consider the social needs and particularities of the school in the territory and may therefore not be meaningful for students. From the perspective of Health Promotion, its fundamental principles, such as equity, empowerment and autonomy, are essential markers for evaluating actions and policies, especially at school (Ministry of Health, 2021; PAHO, 2022). The historical-cultural approach is essential for considering the economic, social, cultural and other contexts of the place where these actions are implemented, to achieve effective health. (Lima et al., 2020; Silva et al., 2023).

Including mental health in the school curriculum would be an assertive strategy as it could address this issue across all school subjects. This strategy is in line with the study by Shilubane et al. (2014), which focusses on the voices of schoolchildren, emphasizing the need to include mental health and suicide prevention in the curriculum, thereby allowing teachers to work on the subject more safely and continuously.

CONCLUSION

The historical-cultural approach is essential to understanding the production of health. The interaction between individuals and the concept of mediation are crucial to both promoting health and understanding the processes that lead to burnout and illness. From this perspective, each person is unique and has a history of specific social interactions, influenced by their culture and context. These experiences shape the way they act and think. When these factors are considered and there is an encounter between individuals, the process of signification and re-signification therefore becomes a fundamental part of mediated experiences, enabling transformations (Vygotsky, 1996). Schools have a fundamental role to play in providing a conducive environment for the development of protective factors for adolescents with suicidal behavior, by strengthening affection and bonds between peers and teachers that can be healthy. This approach to preventing suicidal behavior is unique, but actions to prevent suicide at school are limited by resistance, and lack of support and knowledge on the part of school management. In this context, there is a shortage of initiatives to promote mental health and suicide prevention and when there are actions related to the issue, they are isolated and ignore the specificity of each school. The consequence of these actions is an outdated concept of behavior (Vygotsky, 2009), which impacts the actions of school professionals in suicide prevention.

Faced with this problem, possible strategies for overcoming these challenges include incorporating mental health into the school curriculum, training nursing and education staff about suicidal behavior and recognizing the importance of health professionals in this context as mental health promoters.

The limitations of this study are related to the global context of COVID-19, which has reconfigured the ways of working and conducting scientific research.