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Aquichan

Print version ISSN 1657-5997On-line version ISSN 2027-5374

Aquichan vol.21 no.3 Bogotá July/Sept. 2021  Epub Sep 30, 2021

https://doi.org/10.5294/aqui.2021.21.3.3 

Articles

Self-inflicted injuries among adolescents: Prevalence and associated factors, Espírito Santo, Brazil*

Lesión autoprovocada entre adolescentes: prevalência y factores asociados, Espírito Santo, Brasil**

Lesão autoprovocada entre adolescentes: prevalência e fatores associados, Espírito Santo, Brasil***

Mayara Alves Luis 1  
http://orcid.org/0000-0002-5162-8899

Nataly Adriana Jiménez Monroy 2  
http://orcid.org/0000-0003-4593-9479

Luciana Graziela de Godoi 3  
http://orcid.org/0000-0002-1681-0281

Franciéle Marabotti Costa Leite 4  
http://orcid.org/0000-0002-6171-6972

1 Universidade Federal do Espírito Santo, Brazil. mayara.lu¡s@edu.ufes.br

2 Universidade Federal do Espírito Santo, Brazil. nataly.monroy@ufes.br

3 Universidade Federal do Espírito Santo, Brazil. luciana.godoi@ufes.br

4 Universidade Federal do Espírito Santo, Brazil. franciele.leite@ufes.br


ABSTRACT

Objective:

To identify the prevalence of notified self-inflicted injuries among adolescents in Espírito Santo and to analyze the associated factors.

Materials and methods:

A cross-sectional and analytical study, with the notified data of self-inflicted violence among adolescents in Espírito Santo registered in the Notifiable Diseases Information System from 2011 to 2018. The bivariate analyses considered the Chi-square (x2) and Fisher's Exact tests. The multivariate analysis considered the log-binomial model, and the adjustment results were presented as prevalence ratio.

Results:

The prevalence of notified self-inflicted injuries was 33 % and, of this total, 79.8 % occurred among female adolescents. Prevalence was higher among adolescents aged from 13 to 17 years old (female gender) and from 18 to 19 years old (male gender), as well as among those with some disability or disorder. Higher prevalence values were found in the residence and in collective housing, as well as among those who did not consume alcohol at the event in question. In the female gender, there was also an association with the urban area (p < 0.05).

Conclusions:

hHigh prevalence of notified self-inflicted injuries is perceived among adolescents in Espírito Santo, as well as of the factors associated to this phenomenon. The importance of adopting promotion, prevention and recovery measures for the problem is verified.

KEYWORDS (Source DeOS): Adolescent; attempted suicide; self-injurious behavior; epidemiology; health information systems

RESUMEN

Objetivo:

identificar la prevalencia de lesiones autoprovocadas notificadas entre adolescentes en Espírito Santo, Brasil, y analizar los factores asociados.

Materiales y métodos:

estudio analítico de tipo transversal, a partir de datos notificados de violencia autoprovocada entre adolescentes en Espírito Santo registrados en el Sistema de Información de Problemas de Salud y Notificación entre 2011 y 2018. En los análisis bivariados se consideraron las pruebas de chi-cuadrado (x2) y exacta de Fisher. El análisis multivariado adoptó el modelo log-binomial, y los resultados del ajuste se presentaron a partir de la razón de prevalencia.

Resultados:

la prevalencia de lesiones auto-provocadas notificadas fue del 33 % y, de este total, el 79,8 % ocurrió entre adolescentes del género femenino. La prevalencia fue mayor en adolescentes de 13 a 17 años (sexo femenino) y de 18 y 19 años (sexo masculino), y entre aquellos con alguna discapacidad o trastorno. Se encontraron valores de prevalencia más elevados en la vivienda y en alojamiento compartido, y entre aquellos que no consumieron alcohol en el evento en cuestión. En el sexo femenino, también se registró una asociación con el área urbana (p < 0,05).

Conclusiones:

se percibe la elevada prevalencia de lesiones autoprovocadas notificadas entre los adolescentes en Espírito Santo y los factores asociados a este fenómeno. Se evidencia la importancia de adoptar medidas de promoción, prevención y recuperación del problema.

PALABRAS CLAVE (Fuente DeOS): Adolescente; intento de suicidio; conducta autodestructiva; epidemiología; sistemas de información en salud

RESUMO

Objetivo:

identificar a prevalência de lesão autoprovocada notificada entre adolescentes no Espírito Santo e analisar os fatores associados.

Materiais e métodos:

estudo analítico do tipo transversal, com os dados notificados de violência autoprovocada entre adolescentes no Espírito Santo registrados no Sistema de Informação de Agravos e Notificação de 2011 a 2018. Análises bivariadas consideraram o teste Qui-Quadrado (x2) e o exato de Fisher. A análise multivariada considerou o modelo log-binomial, e os resultados do ajuste foram apresentados em razão de prevalência.

Resultados:

a prevalência de lesão autoprovocada notificada foi 33 % e, desse total, 79,8 % ocorreram entre adolescentes do sexo feminino. Houve maior prevalência em adolescentes com idade de 13 a 17 anos (sexo feminino) e de 18 a 19 anos (sexo masculino), e entre aqueles com deficiência ou transtorno. Maiores prevalências foram encontradas na residência e na habitação coletiva, e entre aqueles que não consumiram álcool no evento. No sexo feminino, também houve associação com a zona urbana (p < 0,05).

Conclusões:

percebe-se a alta prevalência de lesão autoprovocada notificada entre os adolescentes no Espírito Santo e os fatores associados a esse fenômeno. Constata-se a importância da adoção de medidas de promoção, prevenção e recuperação contra o agravo.

PALAVRAS-CHAVES (Fonte DeOS): Adolescente; tentativa de suicídio; lesão autoinfligida não suicida; epidemiologia; sistema de informação em saúde

Introduction

Adolescence can be considered as a stressful event for the individual due to the multiple and intense physiological and physical changes that occur during this period 1. In this phase, where the person is vulnerable, there may be reactions with suicidal attitudes in response to conflicts, either internal or external 2. In this context, self-inflicted injuries among adolescents became a public health problem and drew attention due to the severity of their impacts 3,4.

There can be self-inflicted injuries with or without suicidal ideation. Self-inflicted injuries with suicidal ideation are called "attempted suicide" and occur when the individuals try to put an end to their own life, although without consummation 5. In turn, self-inflicted injuries are defined as the direct and deliberate destruction of one's own body tissue in the absence of lethal intent and for reasons not socially established 6.

Although they are commonly classified as similar acts - since, generally, non-suicidal injuries are treated as attempted suicide 7,8 - the literature 7 points out relevant differences between them, such as: the intention to die present only in attempted suicide while, in non-suicidal injuries, the intention is to achieve relief of unwanted feelings (7, 9); the difference between the most commonly used means of aggression since, in suicide attempts, they are more aggressive 6; the psychological consequences, which are generally of relief after the act of self-inflicted injury without suicidal intention and of failure after attempted suicide 7; and the number of times the individuals attack themselves, with the frequency of self-inflicted injuries without the suicidal intention being higher 7.

Although these differences exist, these practices are related to each other and, according to some studies, adolescents involved in non-suicidal injury practices are more likely to attempt suicide at some point in their lives 10,11.

According to some studies 12,13, the incidence of self-inflicted injuries in adolescents can be conceptualized from a three-level iceberg model. At the first level is a suicide, which is the fatal and less common outcome; at the second level are injuries, which result in health care services; and, finally, self-inflicted injuries, which occur in the community, being the most common, but hidden for the most part.

In a meta-analysis conducted with studies produced in 41 countries, the prevalence of self-inflicted injuries throughout life was 16.5 % 14. A systematic review that aimed at estimating the prevalence of suicidal behavior, deliberate self-injury and non-suicidal self-injury in children, and adolescents worldwide, indicated that the lifetime prevalence of attempted suicide was 6 %, while injury without suicidal intent presented a prevalence of 22.1 % 15. Between 2011 and 2014, in Espírito Santo, the notification rate of self-inflicted injuries was 22.8 cases among female adolescents in the age group from 15 to 19 years old for every 100,000 adolescents 16.

In the literature, many factors have been associated with the practice of self-inflicted injuries in adolescence, such as: gender; age; the presence of mental disorders; having feelings of guilt, rejection and loneliness; family and peer conflicts; being a victim of bullying; having been a victim of domestic violence, and consumption of alcoholic beverages 17-21.

In Brazil, Ministry of Health Ordinance 1,271 of 2014 incorporated self-inflicted violence to the national list of immediate and mandatory notification health problems, to ensure intervention in cases through the health sector 22. Therefore, a mandatory notification is an institutional duty, and it is up to the health professionals to report the cases in full compliance with the current legislation 23.

Given the above, the objective of this study is to analyze the factors associated with the occurrence of self-inflicted injuries and the characteristics of both the victims and the aggressions among adolescents in Espírito Santo.

Materials and method

This is an epidemiological, analytical and cross-sectional study, carried out with the notified data of self-inflicted and interpersonal violence against adolescents, aged between 10 and 19 years old, produced by the epidemiological surveillance system and registered in the Notifiable Diseases Information System (Sistema de Informação de Agravos de Notificação, SINAN).

The SINAN is one of the health information systems fed by the notification and investigation of cases of mandatory notification diseases and health problems, such as interpersonal and self-inflicted violence. Its objective is to collect, transmit and disseminate data generated by the Epidemiological Surveillance System to support the investigation process and provide subsidies for the analysis of the epidemiological surveillance information regarding the mandatory notification problems 24. For this research, the data used were those from the notifications of self-inflicted injuries among adolescents from 2011 to 2018 produced by the State Health Secretariat of Espírito Santo.

Espírito Santo is a state located in the Brazilian Southeast region, with a territorial extension of 46,074.444 km2. According to the last demographic census conducted in 2010 by the Brazilian Institute of Geography and Statistics, it had nearly 3.5 million inhabitants, with an estimated population of 603,835 adolescents at the time, a demographic density of 76.25 inhabitants/km2, and a human development index of 0.740 25.

Initially, a descriptive exploratory analysis was performed to qualify the variables of interest and correct the inconsistencies in the database, following the guidelines of the Tutorial for the Notification of Interpersonal and Self-Inflicted Violence. Immediately after that, the duplicate cases were verified and later excluded. It is worth noting that duplicates were analyzed by organizing the records by notification date, comparing occurrence date, name of the victim, and of the mother, and date of birth.

The dependent variable of the study was "self-inflicted injuries". According to the tutorial for filling out the interpersonal/ self-inflicted violence notification forms, self-inflicted injuries are considered as those cases in which the individuals assisted/victims provoked aggression against themselves or attempted suicide; as well as attempted suicide and the act trying to put an end to one's life, although without consummation 23.

The following were chosen as independent variables for this study: age (from 10 to 12 years old, from 13 to 17 years old, from 18 to 19 years old), race/skin color (white/non-white), disability/ disorder (no/yes), area of residence (urban/rural, peri-urban), place of occurrence (residence/school/collective housing/others), other occurrences (no/yes), means of aggression (poisoning, intoxication/sharps/others), and suspected alcohol consumption (no/yes).

As the objective is to adjust a regression model, the database used in all analyses of this study considered only those forms that had all the independent variables filled in according to the categorization of the variable considered. From 2011 to 2018, a total of 3,410 forms with this characteristic were obtained, of which 1,131 corresponded to the notifications of self-inflicted violence.

The data were analyzed through descriptive statistics in absolute and relative frequencies, with 95 % confidence intervals. The bivariate analyses were performed using the Chi-square (x2) and Fisher's Exact tests according to the assumption, with a 95 % significance level. The association between the independent variables and the outcome under study was assessed based on the non-adjusted and adjusted prevalence ratios. To obtain the adjusted measures, the log-binomial regression model was considered, as the response variable is dichotomous and there is interest in knowing if the prevalence ratios are obtained.

In the initial analysis of the model, all the dependent variables proposed in this study were considered. However, it was verified that the "means of aggression" variable in the modeling is acting as a confounding variable due to its almost perfect association with the response variable. For example: for the female adolescents, the polychoric correlation between the outcome and the "means of aggression" variable is 0.97. In addition to that, 93.44 % of the cases of self-inflicted injuries among adolescents were with sharps or by poisoning/intoxication. These means were used by only 7 % of the aggressors against the female adolescents who suffered types of violence other than self-inflicted. Such phenomenon also occurs among male adolescents. If this variable is retained in the model fit, negative impacts on the results range from non-significance of notably relevant variables, such as age group, to drastic underestimation of the prevalence ratios. Another negative impact concerns the modeling technique, in which, with the presence of the "means of aggression" variable, only the Poisson regression model with robust variance can be considered, a method that is often used as an approximation of the log-binomial model. A permanence of the variables in the model was considered for p < 0.05. The bivariate analyses were performed in the STATA 13.0 program, and the log-binomial modeling was conducted by using the logbin package from the R software, version 4.0.0.

The study was approved by the Research Ethics Committee of Universidade Federal do Espírito Santo, under Opinion No 2,819,597, and all rules and guidelines outlined in Resolution 499/2012 were respected.

Results

Between 2011 and 2018, the prevalence of self-inflicted injuries among the notified cases of violence was 33.2 % (N = 1,131; 95 % CI = 31.60-34.76) among adolescents in Espírito Santo, of the total violence notification forms filled out in this period. Among the cases of self-inflicted violence, 79.8 % of the adolescents were female, 69.9 % were aged between 13 and 17 years old, 68.7 % were of non-white race/skin color, nearly 25.3 % presented some disability/disorder, and 90.7 % lived in the urban area. As for the characteristics of the self-aggressions, most of them occurred in the residence (88.4 %), were recurrent (52.8 %), the most prevalent means of self-inflicted aggression was poisoning/intoxication (65.1 %) and, in 9.1 % of the cases, there was suspicion of alcoholic beverage consumption at the event in question.

Table 1 Characteristics of the notified cases of self-inflicted violence among adolescents aged from 10 to 19 years old.Espírito Santo, 2011-2018 (N = 1,131) 

Variables N (%) CI (95 %)
Gender
Male 228 20.2 17.91-22.60
Female 903 79.8 77.39-82.08
Age
10-12 years old 100 8.9 7.31-10.64
13-17 years old 791 69.9 67.19-72.54
18-19 years old 240 21.2 18.93-23.70
Race/Skin color
White 354 31.3 28.65-34.06
Non-white 777 68.7 65.93-71.34
Disability/Disorder
No 845 74.7 72.09-77.16
Yes 286 25.3 22.83-27.90
Area of residence
Urban 1,026 90.7 88.87-92.27
Rural/Peri-urban 105 9.3 7.72-11.12
Place of occurrence
Residence 1,000 88.4 86.41-90.15
School 68 6.0 4.76-7.55
Collective housing 14 1.3 0.73-2.08
Others 49 4.3 3.28-5.68
Other occurrences
No 534 47.2 44.31-50.13
Yes 597 52.8 49.86-55.68
Means of aggression
Poisoning/Intoxication 737 65.1 62.33-67.89
Sharps 280 24.8 22.32-27.36
Others 114 10.1 8.45-11.97
Suspected use of alcohol
No 1,028 90.9 89.06-92.43
Yes 103 9.1 7.56-10.93

Source: Elaborated by the authors.

In the bivariate analyses described in Table 2, it is verified that self-inflicted injuries in both genders were related to age, race/skin color, disability/disorder, place of occurrence, means of aggression, and suspected alcohol consumption (p < 0.05). In the female gender, the "area of residence" variable was also associated, as well as "other occurrences" p < 0.05).

Table 2 Distribution of the characteristics of the notifications of self-inflicted violence among adolescents, by gender. Espírito Santo, 2011-2018 

Variables Female (N = 903) Male (N = 228)
N (%) CI (95 %) p-value N (%) CI (95 %) p-value
Age group
10-12 years old 84 21.9 18.06-26.36 0.000 16 10.2 6.32-16.01 0.000
13-17 years old 654 41.2 38.85-43.70 137 25.6 22.03-29.43
18-19 years old 165 29.1 25.50-32.98 75 41.2 34.26-48.52
Race/Skin color
White 276 39.6 36.02-43.28 0.010 78 30.9 25.53-36.94 0.036
Non-white 627 34.1 31.97-36.31 150 24.1 20.87-27.59
Disability/ Disorder
No 678 30.5 28.65-32.49 0.000 167 22.5 19.66-25.69 0.000
Yes 225 71.4 66.18-76.15 61 45.5 37.25-54.04
Area of residence
Urban 826 36.4 32.35-34.85 0.014 200 26.4 23.39-29.68 0.536
Rural/Peri-urban 77 28.8 21.41-28.66 28 23.7 16.88-32.27
Place of occurrence
Residence 804 43.0 40.76-45.25 196 41.7 37.31-46.22
School 57 41.0 33.11-49.39 0.000 11 16.2 9.14-27.01 0.000
Collective housing 6 35.3 16.35-60.34 8 47.1 24.95-70.37
Others 36 7.1 5.14-9.65 13 4.1 2.36-6.87
Other occurrences
No 405 32.6 30.05-35.26 0.002 129 23.9 20.47-27.67 0.064
Yes 498 38.5 35.89-41.20 99 29.5 24.89-34.67
Means of aggression
Poisoning/ Intoxication 608 96.2 94.39-97.44 129 97.0 92.22-98.87
Sharps 226 73.1 67.90-77.79 0.000 54 50.0 40.62-59.37 0.000
Others 69 4.33 3.43-5.44 45 7.1 5.33-9.38
Suspected use of alcohol
No 832 42.9 40.69-45.10 0.000 196 29.2 25.88-32.77 0.000
Yes 71 11.9 9.59-14.79 32 15.7 11.29-21.36

Source: Elaborated by the authors.

The non-adjusted and adjusted analyses of the cases of self-inflicted violence in the male gender are presented in Table 3. It is observed that the prevalence of self-inflicted injuries among boys is 4.03 times higher in those aged 18 and 19 years old when compared to the younger group (10-12 years old) and 1.47 times more prevalent among those who presented some type of disability or disorder. As for the characteristics of the self-aggressions, it is noted that, among boys, this type of violence is more frequent in the residence and in collective housing when compared to other possible locations (PR = 10.22; 95 % CI = 5.96-17.54; PR = 10.20; 95 % CI = 5.06-20.59). Regarding suspected alcohol consumption, a higher prevalence of self-inflicted injuries was observed among adolescents who were not suspected of having consumed alcohol (PR = 1.82; 95 % CI = 1.34-2.48) (p < 0.05).

Table 3 Non-adjusted and adjusted analyses of the effects of the characteristics of the self-inflicted violence cases among male adolescents (N = 228). Espírito Santo, 2011-2018 

Variables Non-adjusted analysis Adjusted analysis
PR CI (95 %) p-value PR CI (95 %) p-value
Age
10-12 years old 1.0 -- 0.000 1.0 -- 0.000
13-17 years old 2.50 1.54-4.07 2.75 1.73-4.37
18-19 years old 4.04 2.46-6.64 4.03 2.53-6.41
Race/Skin color
White 1.28 1.02-1.62 0.033 1.09 0.95-1.25 0.216
Non-white 1.0 -- 1.0 --
Disability/Disorder
Yes 2.01 1.60-2.53 1.47 1.25-1.73
No 1.0 -- 0.000 1.0 -- 0.000
Area of residence
Urban 1.11 0.78-1.57 0.541 1.09 0.83-1.42
Rural/Peri-urban 1.0 -- 1.0 -- 0.533
Place of occurrence
Residence 10.26 5.96-17.67 10.22 5.96-17.54
School 3.98 1.86-8.51 4.27 2.00-9.11
Collective housing 11.58 5.56-24.12 10.20 5.06-20.59
Others 1.0 -- 0.000* 1.0 -- 0.000
Other occurrences
Yes 1.23 0.98-1.54 0.94 0.81-1.09
No 1.0 -- 0.062 1.0 -- 0.397
Suspected use of alcohol
No 1.86 1.32-2.61 1.82 1.34-2.48
Yes 1.0 -- 0.000 1.0 -- 0.000

* Obtained by means of Fisher's Exact test.

Source: Elaborated by the authors.

Table 4 presents the adjusted analyses of the self-inflicted injuries in the female gender. The prevalence of self-inflicted injuries was 73 % higher in girls aged from 13 to 17 years old and among the female adolescents who had some type of disability or disorder. A 19 % increase in the prevalence of the problem is observed among the adolescents who lived in the urban area. In addition, in the female group there was a higher occurrence of the problem in the residence (PR = 5.17; 95 % CI = 3.78-7.09), being 2.96 times higher among those who did not consume alcohol (p < 0.05).

Table 4 Non-adjusted and adjusted analyses of the effects of the characteristics of the self-inflicted violence cases among female adolescents (N = 903). Espírito Santo, 2011-2018 

Variables Non-adjusted analysis Adjusted analysis
PR CI (95 %) p-value PR CI (95 %) p-value
Age
10-12 years old 1.0 -- 0.000 1.0 -- 0.000
13-17 years old 1.88 1.54-2.29 1.73 1.44-2.08
18-19 years old 1.32 1.05-1.66 1.46 1.19-1.80
Race/Skin color
White 1.16 1.03-1.29 1.04 0.95-1.13 0.407
Non-white 1.0 -- 0.009 1.0 --
Disability/Disorder
Yes 2.33 2.12-2.56 1.73 1.59-1.87
No 1.0 -- 0.000 1.0 -- 0.000
Area of residence
Urban 1.26 1.03-1.53 1.19 1.01-1.39
Rural/Peri-urban 1.0 -- 0.020 1.0 -- 0.036
Place of occurrence
Residence 6.07 4.41-8.36 5.17 3.78-7.09
School 5.79 3.99-8.41 4.48 3.11-6.47
Collective housing 4.99 2.43-10.21 3.65 1.91-6.97
Others 1.0 -- 0.000 1.0 -- 0.000
Other occurrences
Yes 1.18 1.06-1.31 0.946 0.87-1.03
No 1.0 -- 0.002 1.0 -- 0.196
Suspected use of alcohol
No 3.59 2.87-4.49 0.000 2.96 2.38-3.68 0.000
Yes 1.0 -- 1.0 --

Source: Elaborated by the authors.

Discussion

From 2011 to 2018, a 33.2 % prevalence of notifications of self-inflicted violence among adolescents was identified in Espírito Santo. The Surveillance of Violence and Accidents in Urgency and Emergency Sentinel Services Survey (Viva Survey) indicated that, in 2017, Brazil presented a 28.8 % prevalence of self-inflicted violence among adolescents 26; whereas a study conducted in an emergency hospital from Alagoas evidenced 26 % occurrence of self-inflicted injuries among the adolescents 27.

It is important to note the higher proportion in the notifications of self-inflicted violence among female victims (79.8 %). Such findings align with the results presented by other studies 16,28-31. These findings are similar because they evidence the self-inflicted injuries that were mostly recorded in girls 18. In England, the prevalence of self-inflicted injuries was also higher in the girls when compared to the boys 12. Added to this fact, a research study conducted in Mexico highlights higher chances of attempted suicide in female adolescents, when compared to their male counterparts 28.

The difference between the genders can be justified as a consequence of the countries' social and cultural context where the girls' status in each society is defined. In societies dominated by men, it is observed that girls can attempt suicide more frequently, taking into account the problems faced regarding the female gender 29. In addition, women present more internalizing disorders, such as depression and anxiety, which reflects in higher frequency values of suicidal ideation and attempted suicide 32.

Regarding the associated factors, in this study, it is verified that male adolescents aged between 18 and 19 years old, as well as female adolescents between the ages of 13 and 17, presented a higher prevalence of self-inflicted injuries. The prevalence values found in this study corroborate the findings from a survey 33, in which suicidal behavior in female adolescents was found to occur with higher prevalence in mid-adolescence. In turn, in the male adolescents, the highest prevalence values were found at the end of the adolescence period, at the ages of 18 and 19 years old. This finding suggests that younger girls may be more likely to seek help to express their emotional problems and, therefore, suicidal behavior is interrupted earlier among them than among male adolescents 34.

Self-inflicted violence among adolescents with some type of disability or disorder was more prevalent when compared to those without these problems, which is in line with another study conducted with data from the SINAN 16. Mental disorders are at least 10 times more prevalent among individuals who already attempted or consummated suicide than in the general population 35. Adolescents with bipolar disorder, eating disorders, melancholic depression or anxiety present higher prevalence values of self-inflicted injuries 19. Corroborating these findings, a research study conducted in the United States shows that the depressive, or bipolar disorders increase the chances of suicidal behavior among adolescents 20. Many suicide attempts can occur impulsively in crisis moments due to a collapse in the ability to deal with life's acute or chronic stress 3. In addition to that, mental disorders such as depression can cause major distress and interfere in the individuals' quality of life 36.

Regarding the area of residence, the outcome prevalence was higher among female adolescents who lived in the urban area. This finding is in line with a study conducted in the United States, where the highest prevalence of non-fatal self-inflicted injuries was found in the urban area 37. In a study conducted in Australia, adolescents living in rural areas felt less lonely when compared to those from urban areas, suggesting greater social support, which is an important protective factor for suicidal behavior 38. It is frequently postulated that cities exert an adverse effect on people's health, since some problems such as mental disorders, exposure to risk behaviors and psychological stressors, may be more present in this area 39.

Concerning the place of occurrence, it is noted that, for girls, the prevalence of self-inflicted injuries was higher in the residence; and, for boys, in addition to the high the prevalence in the residence, prevalence was also significant in collective housing spaces. A study conducted with institutionalized adolescents showed a higher prevalence of suicidal behavior in this group when compared to those who were not institutionalized 40. Thiscan be related to the occurrence of adversities before and during the time of institutionalization, which can lead to depressive symptoms, mainly due to the disruption of bonds 41,42. Regarding self-inflicted injuries that occurred in residences, other studies corroborate this research 21,43. Such occurrence can be higher in these places because of the isolated environment and the feeling of loneliness, which can lead them to self-aggression without being interrupted by others 21.

Regarding the main means of self-aggression used by the adolescents, the highest number of cases of poisoning and/or intoxication and sharps (cutting) is observed, corroborating a research study that used national data from the SINAN 16. Data from a research study conducted by Beckman et al.10 are in line with these findings as they evidence higher prevalence values of self-intoxication and cutting. Self-intoxication was also the most prevalent method in a study conducted in Ireland 44. Data from a research study conducted in England also corroborate this study by evidencing that self-inflicted injuries among adolescents through self-intoxication were the main causes of hospital care after the occurrences. In the same research, self-aggressions with sharps were the most prevalent in the general population 12. The means of aggression pointed out deserve attention, as they can be associated with repeated violence and with consummated suicides. According to studies conducted in Ireland 44,45, adolescents who injured themselves with sharps present higher risks of repeated self-aggressions when compared to those who used other methods.

The highest prevalence of self-inflicted injuries was among adolescents who were not suspected of having used alcohol before the self-aggressions. This association can suggest more premeditation and planning in the aggression attempts since they occur without resorting to alcoholic beverages. However, the occurrence of self-aggression has been associated in the literature with acute alcohol intoxication, as suggested by the data from a meta-analysis article in which acute alcohol consumption increased by up to 37 times the chances of suicide attempts 46.

As of Ordinance 1,271 of the Brazilian Ministry of Health, dated June 6th, 2014, notification of self-inflicted injuries in the health services became of compulsory registration within 24 hours of knowledge of its occurrence 22. In this context, notification is one of the care line dimensions, where it is up to the health team to incorporate the adolescents into a comprehensive protection network for the sake of their own health. Therefore, in addition to the notification, it is important to continue monitoring these young individuals by referring them to appointments with multi-disciplinary teams capable of recognizing and resolutely intervening in suicidal behavior 47.

The study has some limitations, such as selection bias, since it is probable that only the most severe cases that depend on care in health services are notified, which excludes the cases that occur in the community in general; therefore, it is not possible to make inferences regarding the prevalence of the problem in the state. Another limitation refers to the notification instrument, which does not discriminate if the violent event was an attempted suicide or a self-inflicted injury without suicidal ideation. Taking this instrument into consideration, it is also noted as a limitation the fact that it was not possible to analyze other factors associated with the occurrence of self-inflicted injuries among adolescents described in the literature.

Conclusions

This study presents the prevalence of the notified cases of self-inflicted violence in adolescents, a fact until then not explored in Espírito Santo. In addition to that, it also evidences factors such as characteristics of the victim and of the occurrence, associated with the higher prevalence in the notification of this problem.

Identifying the associated factors is crucial for prevention measures to be implemented assertively. It is worth pointing out the need to address and work on this issue to welcome the adolescents and dialog with them, as well as to provide opportuni ties for their needs to be addressed in the health services; thus, training the professionals is an important strategy to prevent self-inflicted violence behaviors from continuing into adulthood and to avoid negative outcomes of this practice.

It is also to be noted the importance of mandatory notification by the health professionals within 24 hours, to ensure timely intervention. Although registration of self-inflicted injuries is a challenge for collective health due to its underreporting, this instrument is fundamental for feeding and strengthening the SINAN as an important tool for epidemiological surveillance and as a signpost for necessary changes by the government, as it allows managers to know the situation of the problem as well as to provide subsidies for decision-making and for the implementation of public policies focused on the theme, which aim at strengthening health care for these individuals within the Brazilian Unified Health System.

Finally, it is suggested that research studies with this population be carried out in the community in general to evidence the reasons, distribution, and impacts of this problem, as well as for promotion, prevention, and recovery measures to be adopted.

References

1. Claumann GS, Pinto A de A, Silva DAS, Pelegrini A. Prevalência de pensamentos e comportamentos suicidas e associação com a insatisfação corporal em adolescentes. J Bras Psiquiatr 2018;67:3-9. DOI: 10.1590/0047-2085000000177 [ Links ]

2. Cicogna JIR, Hillesheim D, Hallal AL de LC. Mortalidade por suicídio de adolescentes no Brasil: tendência temporal de crescimento entre 2000 e 2015. J Bras Psiquiatr 2019;68:1-7. DOI: 10.1590/0047-2085000000218 [ Links ]

3. Saxena S, Krug EG, Chestnov O. World Health Organization. Preventing suicide: A global imperative. Geneva: World Health Organization; 2014. Available from: http://apps.who.int/iris/bitstream/handle/10665/131056/9789241564779_eng.pdf;jsessionid=977D082B754978E54CA1451446031E87?sequence=1Links ]

4. Shain B. Suicide and suicide attempts in adolescents. Pediatrics. 2016;138. DOI: 10.1542/peds.2016-1420 [ Links ]

5. Krug EG, Mercy JA, Dahlberg LL, Zwi AB. The world report on violence and health. Geneva: World Health Organization ; 2002. Available from: https://apps.who.int/iris/bitstream/handle/10665/42495/9241545615_eng.pdfLinks ]

6. Nock MK, Borges G, Bromet EJ, Cha CB, Kessler RC, Lee S. Suicide and suicidal behavior. Epidemiol. Rev. 2008;30:133-54. DOI: 10.1093/epirev/mxn002 [ Links ]

7. Halicka J, Kiejna A. Non-suicidal self-injury (NSSI) and suicidal: Criteria differentiation. Adv Clin Exp Med. Journal 2018;5. Available from: https://pdfs.semanticscholar.org/f425/1ff0f2e7dbe5fbd732e56b46ea5e367ccd2a.pdf?_ga=2.40949922.1611151854.1627309860-1985543323.1623091705Links ]

8. Stanley B, Winchel R, Molcho A, Simeon D, Stanley M. Suicide and the self-harm continuum: Phenomenological and biochemical evidence. Int. Rev. Psychiatry 1992;4:149-55. DOI: 10.3109/09540269209066312 [ Links ]

9. Whitlock J, Muehlenkamp J, Eckenrode J. Variation in nonsuicidal self-injury: Identification and Features of Latent Classes in a College Population of Emerging Adults. J Clin Child Adolesc Psychol 2008; 12. DOI: 10.1080/15374410802359734 [ Links ]

10. Beckman K, Mittendorfer-Rutz E, Waern M, Larsson H, Runeson B, Dahlin M. Method of self-harm in adolescents and young adults and risk of subsequent suicide. J Child Psychol Psychiatr. 2018;59:948-56. DOI: 10.1111/jcpp.12883 [ Links ]

11. Lee S, Dwyer J, Paul E, Clarke D, Treleaven S, Roseby R. Differences by age and sex in adolescent suicide. Aust N Z J Public Health. 2019;43:248-53. DOI: 10.1111/1753-6405.12877 [ Links ]

12. Geulayov G, Casey D, McDonald KC, Foster P, Pritchard K, Wells C et al. Incidence of suicide, hospital-presenting non-fatal self-harm, and community-occurring non-fatal self-harm in adolescents in England (the iceberg model of self-harm): A retrospective study. Lancet Psychiat. 2018;5:167-74. DOI: 10.1016/S2215-0366(17)30478-9 [ Links ]

13. McMahon EM, Keeley H, Cannon M, Arensman E, Perry IJ, Clarke M et al. The iceberg of suicide and self-harm in Irish adolescents: A population-based study. Soc Psychiatry Psychiatr Epidemiol. 2014;49:1929-35. DOI: 10.1007/s00127-014-0907-z [ Links ]

14. Gillies D, Christou MA, Dixon AC, Featherston OJ, Rapti I, Garcia-Anguita A et al. Prevalence and characteristics of self-harm in adolescents: Meta-analyses of Community-based studies 1990-2015. J. Am. Acad. Child Adolesc. Psychiatry. 2018; 57:733-41. DOI: 10.1016/jjaac.2018.06.018 [ Links ]

15. Lim K-S, Wong CH, McIntyre RS, Wang J, Zhang Z, Tran BX et al. Global Lifetime and 12-month prevalence of suicidal behavior, deliberate self-harm and non-suicidal self-injury in children and adolescents between 1989 and 2018: A meta-analysis. Int J Environ Res Public Health. 2019;16:4581. DOI: 10.3390/ijerph16224581 [ Links ]

16. Bahia CA, Avanci JQ, Pinto LW, Minayo MC de S. Notificações e internações por lesão autoprovocada em adolescentes no Brasil, 2007-2016. Epidemiol Serv Saúde. 2020;29. DOI: 10.5123/S1679-49742020000200006 [ Links ]

17. Baiden P, Mengo C, Small E. History of Physical Teen Dating Violence and its association with suicidal behaviors among adolescent high school students: Results From the 2015 youth risk behavior survey. J Interpers Violence. 2019. DOI: 10.1177/0886260519860087 [ Links ]

18. Mokhtari AM, Gholamzadeh S, Salari A, Hassanipour S, Mirahmadizadeh A. Epidemiology of suicide in 10-19 years old in southern Iran, 2011-2016: A population-based study on 6720 cases. J. Forensic Leg. Med. 2019;66:129-33. DOI: 10.1016/jjflm.2019.06.018 [ Links ]

19. Parker G, Ricciardi T. The risk of suicide and self-harm in adolescents is influenced by the "type" of mood disorder. J Nerv Ment Dis 2019;207:1-5. DOI: 10.1097/NMD.0000000000000917 [ Links ]

20. Sharp C, Green KL, Yaroslavsky I, Venta A, Zanarini MC, Pettit J. The Incremental validity of borderline personality disorder relative to major depressive disorder for suicidal ideation and deliberate self-harm in adolescents. J Pers Disord 2012;26:927-38. DOI: 10.1521/pedi.2012.26.6.927 [ Links ]

21. Zhao C, Dang X, Su X, Bai J, Ma L. Epidemiology of suicide and associated socio-demographic factors in emergency department patients in 7 general hospitals in northwestern China. Med Sci Monit. 2015;21:2743-9. DOI: 10.12659/MSM.894819 [ Links ]

22. Ministério da Saúde do Brasil. Portaria n.° 1.271, de 6 de junho de 2014. Define a lista nacional de notificação compulsória de doenças, agravos e eventos de saúde pública nos serviços de saúde públicos e privados em todo o território nacional, nos termos do anexo, e dá outras providências. Diário Oficial da União Jan 2011; seção 1. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2014/prt1271_06_06_2014Links ]

23. Ministério da Saúde do Brasil. Secretaria de Vigilância em Saúde. Viva: instrutivo notificação de violência interpessoal e autoprovocada. Brasília: Ministério da Saúde; 2016. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/viva_instrutivo_violencia_interpessoal_autoprovocada_2ed.pdfLinks ]

24. Ministério da Saúde do Brasil. Secretaria de Vigilância em Saúde. Sinan: normas e rotinas Brasília: Ministério da Saúde ; 2007. Disponível em: http://portalsinan.saude.gov.br/images/documentos/Portarias/Manual_Normas_e_Rotinas.pdfLinks ]

25. Instituto Brasileiro de Geografia e Estatística. Brasil/Espírito Santo Panorama. Disponível em: https://cidades.ibge.gov.br/brasil/es/panoramaLinks ]

26. Secretaria de Vigilância em Saúde, Ministério da Saúde do Brasil. Viva Inquérito 2017: vigilância de violências e acidentes em serviços sentinelas de urgência e emergência - Capitais e municípios. Brasília: Ministério da Saúde ; 2019. Disponível em: https://antigo.saude.gov.br/images/pdf/2019/dezembro/05/viva-inquerito-2017.pdfLinks ]

27. Alves V de M, Silva AMS da, Magalhães APN de, Andrade TG de, Faro ACM e Nardi AE. Suicide attempts in an emergency hospital. Arq Neuropsiquiatr 2014;72:123-8. DOI: 10.1590/0004-282X20130212 [ Links ]

28. Contreras ML, Dávila Cervantes CA. Adolescentes en riesgo: factores asociados con el intento de suicidio en México. Rev. chil. pediatr. 2018;17. DOI: 10.11144/Javeriana.rgsp17-34.arfa [ Links ]

29. Pandey AR, Bista B, Dhungana RR, Aryal KK, Chalise B, Dhimal M. Factors associated with suicidal ideation and suicidal attempts among adolescent students in Nepal: Findings from global school-based students health survey. PLoS ONE 2019;14. DOI: 10.1371/journal.pone.0210383 [ Links ]

30. Hu J, Dong Y, Chen X, Liu Y, Ma D, Liu X et al. Prevalence of suicide attempts among Chinese adolescents: A meta-analysis of cross-sectional studies. Compr Psychiatry 2015; 61:78-89. DOI: 10.1016/j.comppsych.2015.05.001 [ Links ]

31. Darré T, Consuela KAC, Saka B, Djiwa T, Ekouévi KD, Napo-Koura G. Suicidal ideation and suicide attempts in subjects aged 15-19 in Lomé (Togo). BMC Res Notes 2019;12:187. DOI: 10.1186/s13104-019-4233-0 [ Links ]

32. Schrijvers DL, Bollen J, Sabbe BGC. The gender paradox in suicidal behavior and its impact on the suicidal process. J Affect Disord 2012;138:19-26. DOI: 10.1016/jjad.2011.03.050 [ Links ]

33. Boeninger DK, Masyn KE, Feldman BJ, Conger RD. Sex differences in developmental trends of suicide ideation, plans, and attempts among European American adolescents. Suicide Life Threat Behav 2010;40:451-64. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2995258/pdf/nihms160390.pdfLinks ]

34. Beautrais AL. Gender issues in youth suicidal behaviour. Emerg Med Australas 2002;14:35-42. DOI: 10.1046/j.1442-2026.2002.00283.x [ Links ]

35. Bachmann S. Epidemiology of Suicide and the Psychiatric Perspective. Int. J. Environ. Res. Public Health. 2018;15:1425. DOI: 10.3390/ijerph15071425 [ Links ]

36. Lima D. Depressão e doença bipolar na infância e adolescência. J Pediatr 2004;80. DOI: 10.1590/S0021-75572004000300003 [ Links ]

37. Goldman-Mellor S, Allen K, Kaplan MS. Rural/Urban Disparities in Adolescent Nonfatal Suicidal ideation and suicide attempt: A population-based study. Suicide Life Threat Behav 2018;48:709-19. DOI: https://doi-org.ezproxy.lib.ucalgary.ca/10.1111/sltb.12390Links ]

38. Houghton S, Hattie J, Carroll A, Wood L, Baffour B. It hurts to be lonely! Loneliness and positive mental wellbeing in Australian rural and urban adolescents. J Psychol Couns Sch 2016;26:52-67. DOI: 10.1017/jgc.2016.1 [ Links ]

39. Qin P. Suicide risk in relation to level of urbanicity: A population-based linkage study. Int. J. Epidemiol 2005;3:846-52. DOI: 10.1093/ije/dyi085 [ Links ]

40. Zappe JG, Dell'Aglio DD. Comportamentos de risco em adolescentes que vivem em diferentes contextos: família e institucionalização. Rev colomb psicol 2016;25. Disponível em: https://dialnet.unirioja.es/servlet/articulo?codigo=5585493Links ]

41. Lieberknecht Wathier Abaid J, Dalbosco Dell'Aglio D, Koller SH. Preditores de sintomas depressivos em crianças e adolescentes institucionalizados. Univ Psychol. 2010;9:199-212. Disponível em: https://www.redalyc.org/pdf/647/64712156016.pdfLinks ]

42. Álvares A de M, Lobato GR. Um estudo exploratório da incidência de sintomas depressivos em crianças e adolescentes em acolhimento institucional. Temas Psicol 2013;21:151-64. DOI: 10.9788/TP2013.1-11 [ Links ]

43. Sheftall AH, Asti L, Horowitz LM, Felts A, Fontanella CA, Campo JV et al. Suicide in elementary school-aged children and early adolescents. Pediatrics 2016;138. DOI: 10.1542/peds.2016-0436 [ Links ]

44. Bennardi M, McMahon E, Corcoran P, Griffin E, Arensman E. Risk of repeated self-harm and associated factors in children, adolescents and young adults. BMC Psychiatry. 2016;16:421. DOI: 10.1186/s12888-016-1120-2 [ Links ]

45. Cully G, Corcoran P, Leahy D, Griffin E, Dillon C, Cassidy E et al. Method of self-harm and risk of self-harm repetition: Findings from a national self-harm registry. J. Affect. Disord. 2019;246:843-50. DOI: 10.1016/j.jad.2018.10.372 [ Links ]

46. Borges G, Bagge CL, Cherpitel CJ, Conner KR, Orozco R, Rossow I. A meta-analysis of acute use of alcohol and the risk of suicide attempt. Psychol Med 2017;7:949-57. DOI: 10.1017/S0033291716002841 [ Links ]

47. Ministério da Saúde do Brasil. Secretaria de Atenção à Saúde. Linha de cuidado para a atenção integral à saúde de crianças, adolescentes e suas famílias em situação de violências: orientação para gestores e profissionais de saúde. Brasília: Ministério da Saúde ; 2010. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/linha_cuidado_crian-cas_familias_violencias.pdfLinks ]

* This article derives from the dissertation entitled “Self-inflicted violence among adolescents in Espírito Santo: An analysis of notified cases from 2011 to 2018”, presented to the Graduate Program in Collective Health of the Faculty, Universidade Federal do Espírito Santo, Brazil. This research was funded by the Espírito Santo Research Support Foundation (Fapes/CNPq/Decit-SCTIE-MS/Sesa Call No. 3/2018-PPSUS).

** Este artículo deriva de la tesis "Violencia autoprovocada entre adolescentes en Espírito Santo: análisis de los casos notificados de 2011 a 2018", presentada al Programa de Postgrado en Salud Colectiva del Cuerpo Docente, Universidade Federal do Espírito Santo, Brasil. La investigación fue patrocinada por la Fundación de Apoyo a la Investigación de Espírito Santo (convocatoria Fapes/ CNPq/Decit-SCTIE-MS/Sesa n.° 3/2018-PPSUS).

*** Este artigo é derivado da dissertação intitulada "Violência autoprovocada entre adolescentes no Espírito Santo: uma análise dos casos notificados de 2011 a 2018", apresentada ao Programa de Pós-Graduação em Saúde Coletiva do Corpo Docente, da Universidade Federal do Espírito Santo, Brasil. Esta pesquisa foi financiada pela Fundação de Amparo à Pesquisa do Espírito Santo (edital Fapes/CNPq/Decit-SCTIE-MS/Sesa n.o 3/2018-PPSUS).

Theme: Promotion and prevention.

Contribution to the discipline: Given self-inflicted injuries in adolescence, this research presents a relevant contribution to Nursing and Public Health in general, since this problem has serious implications for the health of individuals and is a predictor of suicide. The results evidence the high frequency of the problem, report data about the factors associated with the notification of this phenomenon, and contribute to its identification, confrontation, and prevention. In addition, the study evidences the importance of mandatory notification.

Conflict of interests: None declared.

Funding: This research was funded by the Espírito Santo Research Support Foundation (Fapes/CNPq/Decit-SCTIE-MS/Sesa Call No. 3/2018-PPSUS).

To reference this article / Para citar este artículo / Para citar este artigo: Luis MA, Monroy NAJ, Godoi LG, Leite FMC. Self-inflicted injuries among adolescents: Prevalence and associated factors, Espírito Santo, Brazil. Aquichan. 2021;21(3):e2133: DOI: https://doi.org/10.5294/aqui.2021.21.3.3

Received: October 11, 2020; Revised: May 21, 2021; Accepted: July 16, 2021

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