Cross-National Analysis of the Associations among Mental Disorders and Suicidal Behavior: Findings from the WHO World Mental Health Surveys

Background: Suicide is a leading cause of death worldwide. Mental disorders are among the strongest predictors of suicide; however, little is known about which disorders are uniquely predictive of suicidal behavior, the extent to which disorders predict suicide attempts beyond their association with suicidal thoughts, and whether these associations are similar across developed and developing countries. This study was designed to test each of these questions with a focus on nonfatal suicide attempts. Methods and Findings: Data on the lifetime presence and age-of-onset of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) mental disorders and nonfatal suicidal behaviors were collected via structured face-to-face interviews with 108,664 respondents from 21 countries participating in the WHO World Mental Health Surveys. The results show that each lifetime disorder examined significantly predicts the subsequent first onset of suicide attempt (odds ratios [ORs] = 2.9-8.9). After controlling for comorbidity, these associations decreased substantially (ORs = 1.5-5.6) but remained significant in most cases. Overall, mental disorders were equally predictive in developed and developing countries, with a key difference being that the strongest predictors of suicide attempts in developed countries were mood disorders, whereas in developing countries impulse-control, substance use, and post-traumatic stress disorders were most predictive. Disaggregation of the associations between mental disorders and nonfatal suicide attempts showed that these associations are largely due to disorders predicting the onset of suicidal thoughts rather than predicting progression from thoughts to attempts. In the few instances where mental disorders predicted the transition from suicidal thoughts to attempts, the significant disorders are characterized by anxiety and poor impulse-control. The limitations of this study include the use of retrospective self-reports of lifetime occurrence and age-of-onset of mental disorders and suicidal behaviors, as well as the narrow focus on mental disorders as predictors of nonfatal suicidal behaviors, each of which must be addressed in future studies. Conclusions: This study found that a wide range of mental disorders increased the odds of experiencing suicide ideation. However, after controlling for psychiatric comorbidity, only disorders characterized by anxiety and poor impulse-control predict which people with suicide ideation act on such thoughts. These findings provide a more fine-grained understanding of the associations between mental disorders and subsequent suicidal behavior than previously available and indicate that mental disorders predict suicidal behaviors similarly in both developed and developing countries. Future research is needed to delineate the mechanisms through which people come to think about suicide and subsequently progress from ideation to attempts.

Frozen Chicken for Wild Fish: Nutritional Transition in the Brazilian Amazon Region Determined by Carbon and Nitrogen Stable Isotope Ratios in Fingernails

Objectives: Amazonian populations are experiencing dietary changes characteristic of the nutrition transition. However, the degree of change appears to vary between urban and rural settings. To investigate this process, we determined carbon and nitrogen stable isotope ratios in fingernails and dietary intake of Amazonian populations living along a rural to urban continuum along the Solimoes River in Brazil. Methods: Carbon and nitrogen stable isotope ratios were analyzed from the fingernails of 431 volunteer subjects living in different settings ranging from rural villages, small towns to urban centers along the Solimoes River. Data from 200 dietary intake surveys were also collected using food frequency questionnaires and 24-h recall interviews in an effort to determine qualitative aspects of diet composition. Results: Fingernail delta(13)C values (mean standard deviation) were -23.2 +/- 1.3, 20.2 +/- 1.5, and 17.4 +/- 1.3 parts per thousand and delta(15)N values were 11.8 +/- 0.6, 10.4 +/- 0.8, and 10.8 +/- 0.7 parts per thousand for those living in rural villages, small towns, and major cities, respectively. We found a gradual increase in the number of food items derived from C(4) plant types (meat and sugar) and the replacement of food items derived from C(3) plant types (fish and manioc flour) with increasing size of urban centers. Conclusion: Increasing urbanization in the Brazilian Amazon is associated with a significant change in food habits with processed and industrialized products playing an increasingly important role in the diet and contributing to the nutrition transition in the region. Am. J. Hum. Biol. 23:642-650, 2011. (C) 2011 Wiley-Liss, Inc.

The practice of Information Architecture of websites in Brazil

The project of Information Architecture is one of the initial stages of the project of a website, thus the detection and correction of errors in this stage are easier and time-saving than in the following stages. However, to minimize errors for the projects of information architecture, a methodology is necessary to organize the work of the professional and guarantee the final product quality. The profile of the professional who works with Information Architecture in Brazil has been analyzed (quantitative research by means of a questionnaire on-line) as well as the difficulties, techniques and methodologies found in his projects (qualitative research by means of interviews in depth with support of the approaches of the Sense-Making). One concludes that the methodologies of projects of information architecture need to develop the adoption of the approaches of Design Centered in the User and in the ways to evaluate its results.

Street children and their relationship with the police

Background: This paper explores and analyses the experiences of school-age street children. It specifically addresses the relationship of the street children who live on the streets of Sao Paulo (a large Brazilian metropolis), in relation to their experiences, with the policemen. Methods: The paper is a secondary analysis of date previously collected in 1999. The data were collected through individual semi-structured interviews, with 14 school-age children frequenting two city public refuges, with their legal guardians` consent. The text from transcribed interviews was organized according to the validity norms of `thematic analysis`, a technique of contents analysis method. The decomposing and reconstructing process of that analysis gave rise to thematic categories (among which `the police category`) that represented the reconstruction of the difficulties faced by the children in their development. Results and discussion: The children portrayed the police as an enemy, a fearful figure and one of the most agonizing street experiences. Rarely did the police have a positive image to them. According to the children, police violence occurs in three forms: through systematic police persecution in an effort to remove the children from the streets against their will; actions that had the deliberate intent to humiliate them with verbal or physical aggression; and through alleged sexual abuse, revealed by the children in a veiled manner. The authority that is supposedly intended to protect them is portrayed as one of the most feared social agents. Conclusion: The reported hostile behaviour of the policemen shows the state of vulnerability of those children living on the street. This situation must be focused like a health problem because it causes injury to development of children. Nurses can help them through organizing assistance to children in situation of personal and social risk in the school nursing and health institution.

Dignified death: Concept development involving nurses and doctors in Pediatric Intensive Care Units

The aim of this study was to develop the concept of the dignified death of children in Brazilian pediatric intensive care units (PICUs). The Hybrid Model for Concept Development was used to develop a conceptual structure of dignified death in PICUs in an attempt to define the concept. The fieldwork study was carried out by means of in-depth interviews with nine nurses and seven physicians working in PICUs. Not unexpectedly, the concept of dignified death was found to be a complex phenomenon involving aspects related to decisions made by the multidisciplinary team as well as those related to care of the child and the family. Knowledge of the concept`s dimensions can promote reflection on the part of healthcare professionals regarding the values and beliefs underlying their conduct in end-of-life situations. Our hope is that this study may contribute to theoretic and methodological development in the area of end-of-life care.

Images of a `good nurse` presented by teaching staff

Nursing is at the same time a vocation, a profession and a job. By nature, nursing is a moral endeavor, and being a `good nurse` is an issue and an aspiration for professionals. The aim of our qualitative research project carried out with 18 nurse teachers at a university nursing school in Brazil was to identify the ethical image of nursing. In semistructured interviews the participants were asked to choose one of several pictures, to justify their choice and explain what they meant by an ethical nurse. Five different perspectives were revealed: good nurses fulfill their duties correctly; they are proactive patient advocates; they are prepared and available to welcome others as persons; they are talented, competent, and carry out professional duties excellently; and they combine authority with power sharing in patient care. The results point to a transition phase from a historical introjection of religious values of obedience and service to a new sense of a secular, proactive, scientific and professional identity.

Clinical relationships and ethical problems in primary care, Sao Paulo, SP, Brazil

Objectives: Main Objective: to identify ethical problems in primary care according to nurses` and doctors` perceptions. Secondary Objective: to know ethical issues of patient-professional relationships in primary care. Design: Synthesis to integrate and reinterpret primary results of qualitative studies. Setting: Primary healthcare centers, Sao Paulo, SP, Brazil. Participants and/or context: Incidental sample of 34 nurses and 36 medical doctors working in primary healthcare centers selected by convenience. Methods: Individual, semi-structured interviews to identity situations considered as sources of ethical problems. The sample is socially representative of primary care health centers and professionals. Data collection assured discourse saturation. Hermeneutic-dialectical discourse analysis was used to study the results. Results: Patient-professional relationships and team work were the main sources of ethical problems. The most important problems were patient information, privacy, confidentiality, interpersonal relationship, linkage and patient autonomy. These issues reflect the recent changes in clinical relation ships and show the peculiarities of primary care with its continuous care which lasts a long time. Healthcare involves multiprofessional team work in the midst of the patient claims for autonomy. Good care of patients needs requires a relationship based on communication and cooperation, and includes feelings and values, with communication skills. Conclusions: Ethical problems in primary care are common situations. For quality and humane primary care the relationship should consist of dialogue, trust and cooperation. (C) 2009 Elsevier Espana, S.L. All rights reserved.

Brazilian registered nurses` perceptions and attitudes towards adverse events in nursing care: a phenomenological study

Aim To describe the perceptions and attitudes of registered nurses (RNs) towards adverse events (AEs) in nursing care. Background The professionals` subjective perspectives should be taken into account for the prevention of AEs in care settings. Method Schutz`s social phenomenology was developed. Interviews were conducted with nine Intensive Care Unit RNs. Results The following five descriptive categories emerged: (1) the occurrence of AEs is inherent to the human condition but provokes a feeling of insecurity, (2) the occurrence of AEs indicates the existence of failures in health care systematization, (3) the professionals` attitudes towards AEs should be permeated by ethical principles; (4) the priority regarding AEs should be the mitigation of harm to patients, and (5) decisions regarding the communication of AEs were determined by the severity of the error. Conclusions The various subjective perspectives related to the occurrence of AEs requires a health care systematization with a focus on prevention. Ethical behaviour is essential for the patients` safety. Implications for nursing management Activities aimed at the prevention of AEs should be integrated jointly with both the professionals and the health care institution. A culture of safety, not punishment, and improvement in the quality of care provided to patients should be priorities.

Organ donation: Acceptance and refusal among users of the public health system from Brazil

The present study sought to identify the perception of a given group of users of the Brazilian Public Health System (Sistema Unico de Saude) regarding organ donation and to implement an educational policy. Structured interviews were conducted with the aim of describing the profile of donor and nondonor subjects, the importance of organ donation, and the knowledge regarding donation and brain death. One hundred subjects were interviewed: 33% of them considered themselves potential donors; 40% were donors; 13% were nondonors; and 14% were ill-informed potential donors. However, only 40% of users have already officially expressed to their families a willingness to donate. Regarding their knowledge about the propitious moment for organ donation, only 64% of them associated the donation act with brain death. Although the present results revealed that users of the Brazilian Public Health System are prone to organ donation, there actually was a high amount of refusals, which may be due to lack of information and knowledge regarding the donation-transplantation process.

Women`s feelings about early contact with their infants on the labour ward

Objectives: to identify women`s feelings after early contact with their newborn infants in the delivery room, and to identify how health professionals involved in mother and infant care behave in the intrapartum setting. Design: a qualitative approach using semi-structured interviews and observation. Content analysis was used to derive the three themes that emerged from the interviews. Setting and participants: 23 postpartum women and their caregivers in a public maternity hospital in Ribeirao Preto, Brazil. Findings: three thematic categories emerged from the interviews: heightened fear, severe pain and intense conflict. The professionals` actions revealed that they have theoretical and practical abilities for humanisation of care, but their actions are fragmented. Final considerations: women can feel lonely, fearful and conflicted in the delivery room, and they also experience pain. Giving birth is a major event in a woman`s life, so it is important to facilitate a positive experience. Health professionals were found to display interventionist and impersonal attitudes; these influenced the potential choices of women at their first contact with their infant. Implications for practice: the focus of health care needs to extend beyond the institution. This means fewer normative actions performed by health professionals, enabling women to enjoy their early contact with their newborn infants. (C) 2010 Elsevier Ltd. All rights reserved.

City tuberculosis control coordinators` perspectives of patient adherence to DOT in Sao Paulo State, Brazil, 2005

SETTING: Thirty-six priority cities in Sao Paulo State, Brazil, with a high incidence of tuberculosis (TB) cases, deaths and treatment default. OBJECTIVE: To identify the perspectives of city TB control coordinators regarding the most important components of adherence strategies adopted by health care teams to ensure patient adherence in 36 priority cities in the State of Sao Paulo, Brazil. DESIGN: Qualitative research with semi-structured interviews conducted with the coordinators of the National TB Control Programme involved in the management of TB treatment services in the public sector. RESULTS: The main issues thought to influence adherence to directly observed treatment (DOT) by coordinators include incentives and benefits delivered to patients, patient-health care worker bonding and comprehensive care, the encouragement given by others to follow treatment (family, neighbours and health professionals), and help provided by health professionals for patients to recover their self-esteem. CONCLUSION: The main aspects mentioned by city TB control coordinators regarding patient adherence to treatment and to DOT in Sao Paulo are improvements in communications, relationships based on trust, a humane approach and including the patients in the decision-making process concerning their health.

Maternal decision on obtaining prenatal care: a study in Brazil

Objective: to address the social aspects of pregnancy and the views of pregnant women regarding prenatal assistance in Brazil. Design: this qualitative study was focused on describing the Social Representations of prenatal care held by pregnant women. The discourse of the collective subject (DCS) framework was used to analyse the data collected, within the theoretical background of social representations, as proposed and developed by Serge Moscovici. Participants and setting: 21 pregnant women who were users of the publicly funded Brazilian unified health-care system and resided in the area served by its family health programme in a low- to middle-income neighbourhood on the outskirts of Campo Grande, the capital of the state of Mato Grosso do Sul, in southwestern Brazil. Data were collected by conducting in-depth, face-to-face interviews from January to October 2006. Findings: all participants were married. Formal education of the participants was less than five years in four cases, between five and eight years in six cases, and greater than 11 years in 10 cases. Nine participants had informal jobs and earned up to US$ 200 per month, four paricipants had administrative jobs and earned over US$ 500 per month, and eight participants did not work. No specific racial/ethnic background predominated. Lack of adherence to prenatal care allowed for the identification of two DCS themes: `organisation of prenatal care services` and `lifestyle features`. Key conclusions: the respondents were found to have negative feelings about pregnancy which manifest as many fears, including the fear of harming their children`s health, of being punished during labour, and of being reprimanded by health-care professionals for overlooking their prenatal care, in addition to the insecurity felt towards the infant and self. Implications for practice: the findings reveal that communication between pregnant women and healthcare professionals has been ineffective and that prenatal care has not been effective for the group interviewed-features that are likely to be found among other low- to middle-income groups living elsewhere in Brazil. (C) 2009 Elsevier Ltd. All rights reserved.

Promoting health in families of children with type 1 diabetes mellitus

This paper presents a study of families of children with type 1 diabetes mellitus, emphasizing the identification of social supports and networks to strengthen interventions aimed at health promotion. The approach selected was a qualitative research, using a case study design. Four families of children with diabetes type 1 were studied, totalling seven participants. Data were collected between April and June 2007, through in-depth interviews and the construction of a genogram and an ecomap. The results presented the families` characterization and testimonies grouped in the following categories: social support, social networks and family roles. To promote care in practice, there is a need to identify the characteristics of each family and resources available that provide better living conditions. We concluded that identifying supports and social networks allows for more personalized care delivery to each family with a view to health promotion.

The life impact of burns: the perspective from burn persons in Brazil during their rehabilitation phase

Method. Participants were 18 years of age or older, who had been discharged from hospitalisation between 6 months and 1 year before the interview, or who underwent reconstructive surgery during the previous year, or who were under outpatient follow-up awaiting reconstructive surgery. Data were collected by means of semi-structured interviews. Results. Thirty-eight of the 44 participants (86.4%) reported some type of changes associated with the burn injury, the treatment, or both, regarding the following aspects: work, leisure, relationships, religious ties, educational activities and habits (smoking, using alcohol and drugs and dressing style). The data showed a statistically significant association between burns on at least one of the upper limbs (with or without hands) and changes in work. Conclusions. Some of the aspects mentioned by the participants, such as work and leisure activities, need to be further researched in order to improve our understanding of the impact that these changes causes in the person`s life.

Cultural meaning of quality of life: perspectives of Brazilian burn patients

Purpose. This study was designed to explore the cultural meaning and dimensions of quality of life from the perspective of Brazilian burn patients. Method. A qualitative research approach was used. Nineteen burn patients and their close relatives participated in this ethnographic study. Data were collected by means of direct observation and semi-structured interviews, conducted in a hospital outpatient clinic and during visits to patients` homes. The following inter-related phases guided the analysis process: reading of the material and data reduction, data display, conclusion outlining and verification. Results. Participants reported that the quality of life is related to autonomy and the ability to work. The dimensions of quality of life included: resuming work and functional ability, body image, having leisure and interpersonal relationships. Their descriptions revealed their feelings and attitudes about resuming their previous activities and social lives, particularly concerning the work. Conclusion. For burn patients, quality of life is associated with the concept of normality, the satisfactory performance of social roles in the context of family life and the social world. The results showed the importance of the sociocultural dimension in the concept of quality of life for persons undergoing burn rehabilitation.