Evaluation of Attitudinal Beliefs Held by Medical and Nursing Students Towards Suicidal Behavior

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Editor and Authors,

An exploration of attitudinal beliefs towards suicide behavior in medical and nursing students Mexican medical and nursing students. Also, we compared attitudinal beliefs towards suicide behavior according to the religious of the participants. The type of research should be expected in Methods. Add a very short data analysis. Insufficient keywords, define at least 5.

Introduction

The first paragraph is quite short, it should be longer and you can compare your own country with other world countries.

The whole article should be edited, the words seem to be adjacent to each other.

Why did you choose health departments in particular? The introduction section should be expanded and new sources should be added.

Method

How was the sample size calculated? The power analysis results should be added.

Information that the data collection was done prospectively should be added.

The questionnaire form in which the sociodemographic characteristics of the students were recorded should be mentioned.

Was a normality test performed in statistics? It should be written in order.

According to what were the statistical tests selected?

The data collection date range should be written.

Schools haven't finished their summer vacation yet. Your ethics committee date range is June 8, 2024. How did you collect the data? More importantly, how did you reach the students during their vacation? Give details, love.

Comments for author File: Comments.pdf

Comments on the Quality of English Language

Minör edit

Author Response

REVIEWER 1

Comment 1. An exploration of attitudinal beliefs towards suicide behavior in medical and nursing students Mexican medical and nursing students. Also, we compared attitudinal beliefs towards suicide behavior according to the religious of the participants.

Response 1.

The type of research should be expected in Methods.

Response: We deeply appreciate the reviewer´s suggestion for the all abstract section. We add the type of research in the methods subsection. Page 1 Line 25

Add a very short data analysis.

Response: Done. Change in the manuscript.

In the page 1, Lines 28-30.

Comparison analysis between nursing and medical students were performed. In the comparison, we used Chi-square tests for categorical variable and for continuous variable we used t-tests.

 Insufficient keywords, define at least 5

Response: In this revised version we included two new keywords. Page 1 Line 44.

Keywords: Nursing; Medical; students; Suicide; attitudinal beliefs.

Comment 2. Introduction. The first paragraph is quite short, it should be longer and you can compare your own country with other world countries.

Response 2. we agree. In this revised version we add epidemiologic information.

Change in the manuscript: Page 2, Lines 46-57

Introduction section

For example, epidemiological data showed a mortality rate of 11.3 per 100,000 in Poland, 10.3 to 16.3 per 100,000 in India with a higher risk in men than female [2,3]. Furthermore, North, Central, and South America have experienced a significant increase in suicide mortality over the past 20 years [4]. Furthermore, the death by suicide is the second causes of death in the United State in individuals between 10 to 14 years and 25 to 34 years. And the third cause of death in individuals between 15 to 24 years [5,6]. In Mexico, the deaths by suicide has been increased in the last 5 years, specially between the youth population between 15 to 24 years [7]. Also, recently studies have reported that in Mexican adolescents the suicide attempt increase 600% comparison of 2006 to 2022 [8].

Comment 3. Introduction. The whole article should be edited, the words seem to be adjacent to each other.

Response 3. We improve the writing. We carefully checked and corrected the entire manuscript for typographic, grammatical a formatting errors.

 Comment 4. Introduction. Why did you choose health departments in particular? The introduction section should be expanded and new sources should be added.

Response 4. We followed your suggestion.

We deeply appreciate the reviewer´s suggestion, and have augmented the information to explain, why we choose health departments.

Change in the manuscript.

Page 2, Line 88-80. The suicide behavior is increase in individuals in health care more that the general population. Also, depression, anxiety and suicide behavior has been observed in nursing students [15].

Page 2, Lines 60 -68. Healthcare professionals play a pivotal role in the support and prevention of mental illnesses such as suicide. Especially because healthcare providers influence the motivation or lack thereof to treat patients during a suicidal crisis. However, the attitudes towards suicide behavior could be different between nurses or doctors. The transition of adolescence to adulthood is a significant period of psychological change. Therefore, suicidal ideation is a pivotal role to address in medical and nursing students, which face a wide array of stressors during their education. Health students need to acquire skills and abilities to solve problems which expose students to stressors that could affect their quality mental health

Comment 6. Methods. How was the sample size calculated? The power analysis results should be added.

Response: We apologized because we used a non-probabilistic sampling approach. However, we calculated the power of the present study.

Change in the manuscript.

Page 3, Line 110-11. The present study used a non-probabilistic sampling approach.

Page 3, Lines 159-161. To determine power of present study, we used the G*Power software, using two tails, effect size d=0.5, and sample 1: 195 and sample 2:178, we obtained a power in the present study of 0.98.

Comment 7. Methods. Information that the data collection was done prospectively should be added.

Response: Thanks for your kind comments. Now, we add the time of data collection.

Change in the manuscript.

Page 3, Line 116. The present study and the date collection was conducted from March to July 2024

Comment 8. Methods. The questionnaire form in which the sociodemographic characteristics of the students were recorded should be mentioned.

Response 8. Done

Change in the manuscript:

Assessment procedure:

Page 3, Lines 117-119. We designed a semi structured data sheet. In the first section we obtain sociodemographic information and personal characteristics, lifestyle habits, and other factor were docu-mented by questionnaire.

Comment 9. Methods. Was a normality test performed in statistics? It should be written in order.

Response: We agree with the reviewer. And in the revised manuscript we add the p-value of the Kolmogorov-Smirnov test.

Change in the manuscript

Page 3, Line 148-150. We used the Kolmogorov-Smirnov test for to analyze whether the continuous variables were under normal distribution. We observed a p-value of p>0.08.

Comment 10. Methods. According to what were the statistical tests selected?

Response: In this revised manuscript, we add a sentence that explain the selection of the statistical.

Page 3, Lines 154-156. According the literature, the selection of the statistical test in the present study, was according the type of data (categorical or continuous)[22]

Comment 11. Methods. The data collection date range should be written.

Response: we agree. In this revised version we include the collection date range.

Change in the manuscript.

Page 3, Lines 116.117. The present study and the date collection was conducted from March to July 2024, during the spring class cycle.

Comment 12. Methods. Schools haven't finished their summer vacation yet. Your ethics committee date range is June 8, 2024. How did you collect the data? More importantly, how did you reach the students during their vacation? Give details, love.

Response: Dear reviewer #1, At this point, the authors would like to comment to the reviewer the following: The authors had authorization at the faculty level to carry out the study since March 1, 2024. However, at the institutional level, and after the authors made the corrections requested by the institutional committee, the final acceptance by the institutional committee was on 06/08/2024, as reported at the end of the abstract.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This is an interesting topic of Mexican medical and nurse students attitudinal beliefs towards suicide behaviour. 

Although this is a widely published topic the influence that religion or spirituality has on clinician attitude toward suicidality is novel. That said there is very little in the background information on this.

Introduction

Can the authors please elaborate on why this is potentially an important avenue to research and what previous work has been completed in this area to lead you to this assumption. Also can the authors please clarify the background of the abstract so that the intent of their article is clear.

Results

The authors have cited a previous publication from this study and although the data presented here is different the message is similar. The interesting element of this paper is whether or not there was any influence of spirituality on attitude. Religious data was presented in the demographics table but no analysis was presented to confirm one way or the other of its influence. It is also important to publish negative results.

Can the authors please present some data from the relationship between religious beliefs and attitude toward suicide.

Discussion

The authors seem to have placed an emphasis on the importance of attitudes towards suicidality on palliative care patients and “suicide itself”. The significance of these factors needs to be addressed in the introduction and in the discussion. There is some mention of its potential influence on curriculum taught but again this is not mentioned in the introduction nor is much emphasis placed on it in the discussion.

Can the authors please include some rationale why they think that there could be some link between these two concepts or present reasons why their data has not produced a link. Can the authors please discuss the link between academic educational content, religious experience and resulting clinical care of someone with suicidal behaviour. Please also describe if there are any particular behaviours that potentially have an effect on students.

Comments on the Quality of English Language

The English language of this article does need attending to as the title could create confusion when read with the first line of the abstract. It could suggest that this paper is about levels of suicidality in clinical students based upon their attitude of same.

Author Response

REVIEWER 2

Comment 1. This is an interesting topic of Mexican medical and nurse students attitudinal beliefs towards suicide behavior.

Although this is a widely published topic the influence that religion or spirituality has on clinician attitude toward suicidality is novel. That said there is very little in the background information on this.

Response: We deeply appreciate the reviewer´s comment. We added inserted more information in the introduction section.

Change in the manuscript. Page 2, Lines 70 to 75.

Also, the literature showed that stressful events are associated with risk, but spirituals experiences are associated with protection to the suicide behavior [16,17]. The spirituality has been associated to protection en suicide behavior in students [18]. Also, this factor of protection has been observed in university students [19], in different region of the globe [20]. However, the role of spiritually as a protection against suicide behavior in health students has not been widely studied.

Comment 2. Introduction. Can the authors please elaborate on why this is potentially an important avenue to research and what previous work has been completed in this area to lead you to this assumption. Also can the authors please clarify the background of the abstract so that the intent of their article is clear.

Response: According to the reviewer´s suggestion, we have added the introduction about the avenue to research and our previously work.

Change in the manuscript. Page 2, Line 88-95.

The suicide behavior is increase in individuals in health care more that the general population [24]. Also, depression, anxiety and suicide behavior has been observed in nursing student [25]. Since, the previous work we found the importance to evaluated the attitudes of nursing and medicine students to suicide prevention [26] Nevertheless, there are some many factors that remain unclear; such attitudinal beliefs, which basically are based on the expression of those attitudes. CCCS-18 is a perfect instrument to evaluate and detect self-critical behavior though and a good tool to address the suicide process progression before planning or attempt to suicide [27].

Comment 3. Results. The authors have cited a previous publication from this study and although the data presented here is different the message is similar. The interesting element of this paper is whether or not there was any influence of spirituality on attitude. Religious data was presented in the demographics table but no analysis was presented to confirm one way or the other of its influence. It is also important to publish negative results. Can the authors please present some data from the relationship between religious beliefs and attitude toward suicide.

Response: We agree.  We have augmented the results section. Now, we present all analysis of the relationship between religious beliefs and attitude beliefs on suicide behavior.

Change in the manuscripts. Page, 6 and 7, Lines 195 to 207.

3.4.      Attitudinal beliefs on Suicide Behavior by Religion of the Participant

In the comparison of groups using the religion attendant of the participants, we not observed statistical differences in the four attitudinal beliefs towards suicide behavior. We found similar mean between groups. Table 4.

Table 4. Comparison of attitudinal belief on suicide behavior by religion

 Finally, we assessed whether the attitudinal belief could be modified by the interaction of are a nursing or medic studying and the religion of the participant. However, the results of the multivariable analysis not were statistically significant. Table 5.

Table 5. Results of between variables effects analysis using multivariate ANOVA

Bold type denotes significant p values.

Comment 4. Discussion. The authors seem to have placed an emphasis on the importance of attitudes towards suicidality on palliative care patients and “suicide itself”. The significance of these factors needs to be addressed in the introduction and in the discussion. There is some mention of its potential influence on curriculum taught but again this is not mentioned in the introduction nor is much emphasis placed on it in the discussion.

Response: We deeply appreciate the reviewer’s suggestion, and have made a mention of “suicide itself” in the nursing student.

Change in the manuscript. Page 7-8. Lines 250-255.

Is necessary consider that, nursing students are exposed to pressures from their colleagues, supervisors and teachers. Pressures may increase when a nursing student makes a mistake and possible risk of depression [41]. Therefore, both beliefs and attitudes should be assessed in order to guide prevention programs and curriculums in medical and nursing students, especially in the group of nursing students with high level positive attitude to suicide itself for the prevention of death by suicide[42] .

 Comment 5. Discussion. Can the authors please include some rationale why they think that there could be some link between these two concepts or present reasons why their data has not produced a link. Can the authors please discuss the link between academic educational content, religious experience and resulting clinical care of someone with suicidal behaviour. Please also describe if there are any particular behaviours that potentially have an effect on students.

Response: We apologized for the fact that we did not clearly describe the rationale of suicide behavior and religious experience. In this revised manuscript, we included this rationality.

Change in the manuscript. Page 8, Lines 269-277.

However, in the present work any statistical differences have been found between religion and nursing and medicine students. One explanation could be derived from the religion homogeneity in Mexico. Unlike other countries, most of the Mexican religious cult addressed the Christianity (Pentecostal and Presbyterian, Adventist, catholic, etc); where religion is deeply normalized in everyday life. Hence, the academic educational content and religious experience from nursing and medicine students could impact in attitudinal beliefs and aptitudes toward suicide, which ultimately influences the quality of clinical care and the effectiveness of preventive interventions in patients with suicidal behavior [45,46].

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for responding to the suggestions for amendment, I am satisfied that you have addressed all appropriately. 

Comments on the Quality of English Language

My only suggestion is regarding sentence structure and grammar that does need to be attended to.

Author Response

Thank you for responding to the suggestions for amendment, I am satisfied that you have addressed all appropriately.

Response: Thank you

My only suggestion is regarding sentence structure and grammar that does need to be attended to.

Response: We also carefully checked and corrected the entire manuscript for typographic, grammatical and formatting errors. Language presentation was improved with assistance from a English speaker with appropriate research background.