Healthcare Students’ Knowledge of and Attitude Toward Suicide: A Scoping Review

1. Introduction

According to the World Health Organisation (WHO), suicide has led to the death of 703 000 people globally every year [1]. It was found to be the fourth cause of mortality among 15-30 year-olds and 77% of suicide was reported to occur in low and middle income countries [1]. Due to stigma, legal, and cultural factors, deaths due to suicide are likely underreported and thus the actual prevalence of suicide might be underestimated[2]. Suicide attempts may results in emotional, physical, and economical consequences in individuals and their loved ones [3]. A systemic review reported that suicide-bereaved individuals experience more rejection, stigma, blame, and shame compared to other bereaved groups [4]. In addition, the economic impact of suicide is estimated to be $5.53 billion annually [5]. Given suicide’s public health significance and its preventable nature, the WHO has identified suicide as a serious public health concern [6] and published a report in 2014 to further boost public health awareness around it [7].

Healthcare providers play a crucial role in identifying and preventing suicide. It was found that 44% of individuals visited their physicians a month before they completed suicide [8], however, only 3% of them had their complaints diagnosed as a mental health issue [9]. Indeed, patients reported they had received inappropriate and depersonalized responses with minimal empathy when they talked about suicide [10]. Meanwhile, the management of persons with thoughts of suicide is often impeded by legal, knowledge, emotional, communication, and logistic difficulties [11,12,13]. As a result, clinicians often hold attitudes of avoidance when dealing with suicide attempters, which has led to low-quality, superficial, and inadequate care [14,15]. In addition, a scoping review reported that pharmacists’ role in suicide prevention was affected by barriers, either personal e.g. lack of confidence, training, knowledge; or institutional e.g. work pressure, lack of time or privacy, nonavailability of resources and referral pathways [16]. This has then resulted in persons with thoughts of suicide often refusing to express themselves or seek help from available resources [10].

Based on the assumption that the behaviour of a person is based on their attitude [17], it is important to assess the attitudes of future healthcare providers. Studies indicate that primary care and community pharmacies are the most visited services by individuals prior to suicide, thus it gives these professionals the opportunity to identify individuals with suicidal ideation or those having a mental health crisis [18,19]. Besides, knowledge of suicide should be evaluated as well to ensure continuous systemic improvement in suicide management and health equity [20]. Future healthcare educational curricula that better fulfil public health need could be designed [21] to respond to the WHO’s call to reduce suicide rate by one third by the year 2030 [1]. This scoping review aims to summarize data from the available literature to provide an overview of healthcare students’ knowledge of and attitudes towards suicide and identify gaps as well as interventions needed.

2. Materials and Methods

2.1. Data Sources and Search Strategies

This scoping review followed the methodology outlined by Arksey and O’Malley [22]. Reporting for this review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement for Scoping Reviews (PRISMA-ScR)[23] ((Supplementary Table S1).

Search terms related to “healthcare students”, “knowledge and attitude”, and “suicide” were developed based on the study objectives and a review of the literature, and then further refined after a discussion with the university librarian, as well as among the researchers. Based on the finalized list, a systematic search was performed in the following databases: PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica dataBASE (EMBASE), PsycINFO, and Database of Abstracts of Review of Effects (DARE). The full search strategy is listed in Appendix A. Only primary studies written in English from database inception until 31st December 2023 were included in our review. A manual search was undertaken to identify additional studies from references cited in retrieved articles and a free-hand search was also undertaken via Google Scholar.

All articles obtained from the search were imported into EndNote 20 before being uploaded to Covidence for further screening. After removal of duplicates, two researchers screened the title and abstract of the studies independently (Level 1 screening). The full texts of articles deemed possibly suitable based on the inclusion and exclusion criteria were then reviewed independently by the two researchers (Level 2 screening). Any conflicts that arose were resolved by discussion among the screening researchers, and where consensus could not be reached, the lead researcher (SAJ) was consulted. Ethical approval was not needed for this study as it did not involve human subjects.

2.2. Study Selection

Studies that evaluated the attitude and/ or knowledge of suicide of healthcare students from programmes such as medicine, nursing, pharmacists, dentistry, and allied health such as paramedics, oral health therapists, and dental therapists, were included. The following were excluded: (i) studies that involved healthcare students who had special training in psychiatry such as psychiatric trainees, psychology students, mental health nurses, and midwives, (ii) studies that only evaluated healthcare students’ suicide rate and suicidality, (iii) studies that evaluated healthcare students’ attitude and/ or knowledge on physician-assisted suicide, (iv) studies with outcomes that were not specific, such as the attitudes towards both depression and suicide, (v) in studies where evaluation of an intervention was the focus, pre-test attitudes or knowledge assessments were unavailable, (vi) reviews, systematic reviews, meta-analyses, conference abstracts, conference proceedings, in vivo studies, in vitro studies, animal studies, thesis, and letter to editors, (vii) studies that were not in English, and (viii) studies where abstracts and full texts were not available.

2.3. Data Extraction

Two researchers developed a data extraction sheet specific for the review that included the following details: (1) author, year of publication and the country where the study was conducted, (2) study characteristics including objectives, method, sample size, and study instruments, (3) population demographics including gender, age, study programs undertaken and year of study, (4) outcomes including knowledge and attitudes, and (5) personal experience of suicide and mental health issues. The sheet was pilot tested by two researchers on two articles that were to be included in the scoping review. Further changes were made as appropriate to produce the finalized version. Two researchers then independently undertook the data extraction.

2.4. Data Analysis

Thematic narrative analysis was performed guided by Braun and Clarke [24] to develop themes from the included papers. Results were presented in tabular format and common themes were identified.

3. Results

3.1. Study Search

The database search yielded 1804 articles, while the manual search of the reference lists of potentially relevant articles yielded 10 additional studies as in Figure 1. After exclusion of duplicates and Level 1 screening, 46 articles were included for final analysis where 29 were excluded for the following reasons: did not involve healthcare students or no data specific to healthcare students available (n=11), involved healthcare students trained in mental health (n=6), full texts not available (n=4), studies evaluated post-educational programme findings of interest without pre-programme findings reported (n=5), study involved physician-assisted suicide (n=1) or was not related to suicide (n=1), and one study had no separation of results between depression and suicide. Characteristics of the included studies are detailed in Table 1.

3.2. Study Characteristics

Where reported, the studies included a total of 8094 pre-clinical and clinical healthcare students, with around 65% of them being females and the mean age was 22.0 years old. Data was obtained from various countries, including the United States (US) (n=12) [34,50,51,52,58,67,69,70,84,85,87,89,91,95], Australia (n=5) [46,49,53,65,68], Brazil (n=4) [28,35,37,43], Turkey (n=4) [26,38,71,80], Taiwan (n=3) [59,78,82], India (n=3) [41,74,77], Austria (n=2) [26,74], Japan (n=2)[57,70], and one study each from the United Kingdom (UK) [32], Italy [27], Greece [30], Mexico [36], Bangladesh [44], Nepal [45], Portugal [60], Malaysia [61], Sweden [76], Serbia [79], and Hong Kong [90]. Three studies compared attitudes across different cultures i.e. between American and Japanese students [70], Austrian and Turkish students [26], and Austrian and Indian students [74]. Most studies focused on medical (n=24)[25,26,30,34,36,44,46,49,50,52,53,57,61,68,69,70,71,74,76,79,80,85,89,90] and nursing (n=17)[27,28,35,36,37,38,41,43,45,58,59,60,65,67,77,78,82] students, and a small number on pharmacy (n=5) [51,84,87,91,95], dental (n=1)[32], and paramedic (n=1)[65] students. Data collection was mostly through self-reported surveys incorporating validated or unvalidated questionnaires (n=39)[25,26,27,28,30,32,35,37,38,41,44,45,46,49,50,51,52,53,57,61,65,68,69,70,71,74,76,77,79,80,82,84,85,87,89,90,91,95,99] and interviews (n=8)[34,43,58,59,60,67,68,78]. The majority of studies were published after 2013 (n=33),[25,27,28,30,32,35,36,37,38,41,43,44,45,46,49,51,53,58,59,60,61,65,67,69,77,78,84,85,87,89,90,91,95] and about 50% of the studies (n=25)[25,26,27,28,30,36,37,38,41,45,51,53,60,61,70,74,76,77,78,82,84,87,90,91,95] collected information on personal exposure to suicide or mental health issues.

3.3. Key Findings

Two main themes were developed: (1) knowledge on and skills to manage suicide, and (2) attitude towards suicide. These themes and subthemes are illustrated below.

Theme 1: Knowledge on and skills to manage suicide

Subtheme 1: Skills in managing persons with thoughts of suicide. Six studies involving medical [52,68], nursing [58,59,78], and pharmacy [91] students discussed students’ management skills encompassing suicide risk assessment, identifying those at risk, communicating, and dealing with persons with thoughts of suicide. The skills of the students could be described on a spectrum, whereby some students described themselves as having inadequate skills [58,68,78], while others had high skills [52,58,59,91]. It was noted that skills could be improved over time with increasing contact between clinical staff and persons with thoughts of suicide [59,78]. A study by Neimeyer et al [52] found that among medical students, female gender (p<0.00025), senior students (p<0.029) and those completing inpatient psychiatry rotations (p<0.0004) were significantly associated with better skills than their peers.

Subtheme 2: Knowledge of suicide. Seven studies involving medical [44,46,57], nursing [27], and pharmacy [84,91,95] students evaluated the overall knowledge of students. It was noted that students from developed countries such as Italy [27], Australia [46], Japan [57], and the US [84,91,95] were moderately knowledgeable as compared to their counterparts in Bangladesh who had poor suicide literacy [44]. Several factors that were associated with better knowledge were presence of lifetime suicidal ideation (p =0.020),[27] female gender [44,79], personal or family history of suicide attempts [44], those who attributed suicidal ideation to isolation or depression (p= 0.007), undergraduates (p<0.001), native English speakers (p<0.001),[46] and senior students of their respective courses [46,57].

Eight studies discussed medical [69,85], nursing [67,77], pharmacy [87,91,95], and dental [32] students’ knowledge on suicide risk assessment. There were variations among medical and nursing students, with some being somewhat aware of warning signs [85] and comfortable assessing risks [69,77], while others were uncomfortable to perform suicide risk assessments [67]. Pharmacy students generally displayed good knowledge and readiness in assessing suicide risk [87,91], while 80% of dental students were unsure of what to do if a patient revealed suicidal thoughts [32].

Four studies evaluating students’ knowledge on the causes, nature, treatment, and prevention of suicide discovered that medical [44,57,79,85] and pharmacy [84] students tended to have more knowledge on the treatment and prevention aspects as opposed to the causes and nature of suicide. For example, in a study by Sato et al [57], less than 50% of medical students were able to identify mental disorders and romantic relationship breakdown as risk factors for suicide. Only a few were able to identify the association between gender, age, personality, genetic factors, and history of suicide attempts with suicide. In another study, while more than 75% of medical students were able to identify risk factors for suicide, less than half of them were aware of the predictable nature of suicide [79]. In yet another study, less than 60% of pharmacy students scored correctly on the common means used in suicide attempts and myths related to suicide, such as the tendency of certain age groups or gender to attempt suicide [84]. Medical students, however, scored better when tested on treatment and prevention aspects in two surveys [44,79]. Some of the healthcare students, if not most, were aware of appropriate interventions and measures to help persons with thoughts of suicide [79,84,85].

Subtheme 3: Confidence in managing persons with thoughts of suicide. Nine studies involving medical [34,37,85], nursing [27,28,35,37], and pharmacy[87,95] students highlighted healthcare students’ confidence in managing persons with thoughts of suicide including risk perception and confidence in the ability to help a person at risk or a person who attempted suicide. Overall, most students had low, while some had moderate confidence when dealing with suicidal patients. Nursing undergraduates generally displayed low confidence [27,28,35,37]. A survey done by Marques et al [37] found that males (p=0.00), those who completed a psychiatric nursing course (p=0.01), and those who had previous experience participating in a class or laboratory on suicide (p=0.03) had significantly higher confidence compared to their counterparts.

Meanwhile, Krueger [34] discovered that medical students from the US displayed low confidence in their competence in managing persons with thoughts of suicide, and the trend seemed to remain despite their progression through the course [85]. Medical students showed moderate confidence in another Australian study, with those having previous personal exposure and increased contact with psychiatric patients more confident than the rest of the students [53]. On the other hand, pharmacy students displayed moderate confidence in helping persons with thoughts of suicide as depicted in a simulation video case in a study by Pothireddy [87], though they were less confident in deciding on the appropriate timing for medical intervention [95].

Subtheme 4: Education and training experience in suicide. Seven studies highlighted nursing [28,77,82], pharmacy [51,87,95], and dental[32] students’ engagement in relevant areas of education and training. There was a wide variety in engagement among the healthcare students, however overall, it was still low. Some nursing students had more exposure when compared to other healthcare students, specifically Taiwanese and Brazilian students. Around 50% of Taiwanese students had attended relevant educational courses previously and 40% had professional experience in managing suicide [82], while roughly 35% of Brazilian students participated in suicide prevention classes in the past [28]. Meanwhile, only 5% of nursing undergraduates in India had previous exposure to relevant training and experience [77]. Similarly, less than 15% of pharmacy [51,87,95] and dental students [32] had participated in previous extra-curricular education and courses on suicide. However, notably, among the three dental students who completed suicide awareness training two years prior to the study, one student managed to apply the learning in a real life situation [32].

Theme 2: Attitude towards suicide

Subtheme 1: Emotional reactions when facing persons who are suicidal. There were 16 studies that discussed the emotional impact of dealing with a person with thoughts of suicide on medical [25,26,34,50,57,70,89,90], nursing [27,43,58,59,60,65,67,78], and paramedic [65] students. While some medical students described themselves as not being personally affected,[26,50] others reported a wide range of positive and negative emotions when facing persons with thoughts of suicide. Some of them showed great concern [34] and somewhat sympathized with patients [70,90], though this was less likely among Japanese students whereby less than 50% of them felt sorry for the patients as seen in a study by Sato et al [57]. Others displayed grief, guilt [34], a sense of loss [50], and hostility [34,57].

On the other hand, many nursing undergraduates described feeling apprehensive and fearful that their actions or behaviors might worsen suicidal tendencies [58,59,78]. Some were frustrated as patients continuously ruminated on suicidal thoughts or refused to reveal their thoughts to the students [59], while others described powerlessness in response to similar circumstances [59,78]. In interviews conducted by Zohn et al [67] students disclosed remembering feeling shocked, sad, and angry during various encounters with patients. However, some nursing students and paramedic students did show high levels of empathy to persons with thoughts of suicide [65,67], with some feeling the need to advocate for them [67]. Females (p=0.027) were significantly more likely to empathize [65].

Subtheme 2: Negative and stigmatizing attitudes. Twenty studies revealed negative and stigmatizing attitude towards suicide among medical [25,26,30,36,44,46,61,69,70,71,74,76,79,80,90] and nursing [36,38,41,43,58,78] students. Suicide was depicted by some medical and nursing students as irresponsible especially among final year medical students [76,78], taboo [43,61], and an act borne out of the desire to die and manipulate others [43]. Some disagreed that persons with thoughts of suicide were struggling with isolation or depression [38,80]. Suicide was also seen as selfish [58], stupid [78], cowardly [74], an aggressive act [70], done out of an inability to control rage [71], and contagious [90], and hence should not be normalized [46,80] or glorified [38,46]. In a study conducted by Öz et al [38], suicide was significantly more stigmatized among those who were older (p < 0.05) and those with acquaintances who attempted suicide (p < 0.05).

Among medical students, some of them were unable to accept and understand suicide [61,74] as they agreed that no one had the right to take their own life [30]. Suicide was highly stigmatized [44], deemed morally bad [30], and thought to be punishable after death especially among Turkish [26] and male students [26,30]. A survey undertaken by Emul et al [71] in Turkey discovered that medical students had high levels of distrust about suicide attempters as 80% of them refused to rent a house to suicide attempters, and 90% of them refused to leave their children in the care of a suicide attempter.

Subtheme 3: Permissive or neutral attitudes. Twenty-seven studies highlighted medical [25,26,30,44,46,49,61,69,70,74,76,79,80,89,90], nursing [27,28,35,37,38,41,43,45,60,77,82], and pharmacy [51] students’ relatively permissive attitude toward suicide. Some medical students were reported to have low levels of stigma [46,49]. They disagreed on the taboo placed on the topic [26,80], as they saw suicide as a mental illness or due to despair [30,46,76], particularly among those who were religious [25] and females who were from Austria (p<0.01) [26]. Those with more exposure and knowledge in terms of psychiatry and suicide were also more likely to agree that suicide was an act of communication [61,79], be it to grab the attention of someone [30,79] or for the retaliation or welfare of others [90]. Various possible contributing factors of suicide were acknowledged, including social isolation and depression [44], insecurity [79], and social factors [90]. Regardless, students tended to be neutral in normalizing [49,61], glorifying [44,49], and accepting [26] suicidal behaviour. Japanese students especially were more likely to acknowledge the right to suicide and glorify suicide [70], while Austrians tended to accept suicidal behaviour [26]. Those who were older (p= 0.023), male (p= 0.007), and had a personal history of mental illness (p= 0.005) were significantly more likely to understand and accept suicide as well [61].

Meanwhile, the majority of nursing students held a neutral [45] or positive attitude [28,35,37] toward suicide. Some of them did not have a particular stand on the aspects of morality [82], the right to suicide [27,28,82], suicide as a means of communication [41,43,77,82], and seeing suicide as a mental illness [82]. Others acknowledged the multifactorial influence of suicidal behaviour [60], and hence were less likely to condemn suicidal behaviour [28,35,41]. This was significant among those with a personal lifetime suicidal ideation (p= 0.040) [28], those who were older (p < 0.001) [41], and those with increased exposure to suicide via reading materials (p = 0.01)[37] or practicum (p < 0.001) [41].

Subtheme 4: Perceived nature of suicide. Nineteen studies discussed the perception of medical [34,36,49,68,69,70,71,74,79,80,85,89,90], nursing [36,43,45,60,77], pharmacy [91], and dental [32] students on the nature of suicide. Medical [68,69,79,80,85], pharmacy [91], and dental [32] students were inclined to agree that suicide is preventable, despite the fact that more than 50% of students [71,100] were unsure or disagreed on the predictability of suicide especially those who had a lack of clinical exposure to persons with thoughts of suicide [45,71]. On the contrary, nursing students agreed that suicide was difficult to identify and prevent [60] as the underlying cause of socioeconomic disparity [77] and society’s stigma [60] was not resolved.

Some medical [80] and nursing [43] students also reported that suicide was incomprehensible to them, especially those who were of a younger age (p=0.046) and had never attended relevant psychiatric training (p= 0.021) [45]. Medical students from Turkey [71,80] were more likely to agree that suicide was an impulsive act with low controllability [49], whereas students from Austria [74] and the US [89] were inclined to agree on the deliberate nature of suicide.

Subtheme 5: Role in suicide prevention and management. Twenty studies highlighted medical (n=12)[25,26,34,36,50,68,69,76,80,85,89,90], nursing (n=6) [36,41,58,67,77,82], pharmacy (n=3) [51,87,91], and dental (n=1)[32] students’ perceived role in suicide prevention and management. The majority of students from all fields expressed their agreement on their professional role to prevent [32,34,41,51,69,77,82] and manage [82] suicide except one study where more than 50% of nursing students were defensive about any prevention effort for suicide [77]. Most of them disagreed that suicide prevention or treatment was wasteful [36,69,77] or a misuse of medical resources [76]. They believed that with nurses playing a supportive role in the healthcare system [67,87,90], persons with thoughts of suicide could get better [87].

Despite showing concern for suicide prevention [50] and management via psychiatric treatment and antidepressants [76], some medical students reported being underequipped with suicide prevention skills [80]. They expressed interest for further relevant training as they acknowledged the importance of acquiring suicide prevention skills as a future healthcare professional [68]. Amiri et al [25] and Eskin et al [26] found that students had high social acceptance and desire to help their suicidal friends, especially those who were female (p=.012) [25]. Students would also intervene at times when needed [85], including inquiring into suicidal behaviour, especially among the Austrians [26], or accompanying the person to the healthcare services [85].

4. Discussion

This scoping review provides an overview of healthcare students’ knowledge of and attitude towards suicide. Learning how healthcare students view and think about suicide is vital as this will affect the care provided to the patients in the future. From here, strategies could be devised to develop or improve educational programmes and build healthcare professionals that are able to provide holistic management and care to aid the survival of patients who are suicidal [101].

From this scoping review, it was found that on the whole, healthcare students were generally concerned about persons with thoughts of suicide. Findings involving healthcare professionals were similar, as they tended to admit patients at risk and consult other colleagues after witnessing inpatient suicides [102,103]. Healthcare students also demonstrated relatively high levels of knowledge towards prevention and treatment of suicide, as opposed to the cause and nature, highlighting the tendency of the public be reactive rather than proactive when dealing with mental health issues [104].

This scoping review also found that some nursing students were better prepared with higher professional skills in the management of persons with thoughts of suicide and had good knowledge, given their relatively better training and exposure to suicide [105], which was still overall quite low. This finding supports the literature in highlighting the importance of training in improving knowledge and attitude towards suicide [106,107,108,109,110,111,112,113,114]. Overall, they still reported low confidence in providing management due to the fear of saying something inappropriate and making the situation worse [115]. The findings among nursing students were similar to that from nursing professionals, whereby a majority of them reported low confidence in management given the minimal training and education on suicide received [116,117]. In our scoping review, nursing students saw suicide as a means to communicate, and agreed that victims were often struggling with isolation or depression, consistent with present studies [118,119]. However, they tended to avoid talking about suicide as they felt anxious and powerless from the inability to help and the lack of therapeutic response despite best care [120]. Nursing students were also less likely to stigmatize and judge against persons with thoughts of suicide. This was inconsistent with findings among nursing professionals who viewed suicide as morally wrong or as a mental illness [121,122,123,124,125], although they showed an improvement in attitude over time due to increased training and education on suicide [126,127].

Like doctors [128], medical students were also more likely to condemn the rights to suicide, as they tended to stigmatize against suicide and agree that suicide is not a normal phenomenon that should be glorified. This could be due to the association of suicide with personal weakness, which was commonly stigmatized against in an academically competitive environment [129]. The lack of training and education played a role as well [106,107,108,109,110,111,112,114,130]. Negative attitude and stigma against suicide has been reported to lead to compromised healthcare [131,132,133], and this could explain the lower ability of medical students in managing persons with thoughts of suicide. The provision of less than optimal care to those with thoughts of suicide was also noted in a study involving primacy care physicians [134,135,136,137].

Cultural and religious influences could shape attitudes towards suicide. For example, Austrian and Japanese students were more likely to normalize and glorify suicide. For the Japanese, suicide was historically honourable when done to gain control on life [138] or over death [139]. Meanwhile, findings for Austrian students indicated that suicide was seen as a deliberate act and a decision with rationale [74] and should be respected. Meanwhile, Turkish students were more likely to believe that suicide would lead to punishment after death, as Islam viewed suicide as sinful[140] and prohibited suicide strictly [141]. In this review, Indian students completely rejected suicide since it was seen as a cowardly and impulsive act from uncontrolled emotions and mental illness [74]. Traditionally in the Indian culture, suicide is deemed as a sign of “weakness of mind”, and that those who carried out suicide were expected to be “stronger” and “seek solution from God” [114]. Those who attempted suicide are blamed and showered with guilt [114], although Hinduism (adhered to by 80% of Indian population)[142] does not specifically prohibited suicide [143], indicating a larger role of culture compared to religion in this context. Despite urges to decriminalise suicide, suicide remains a criminal offense to date [144], which might have contributed to the attitude of the Indian students as well.

Demographics seemed to play a role whereby our review suggested females were more likely to have better knowledge, skills and attitude, and increased perception of personal role and responsibilities in suicide management and prevention. They displayed higher levels of empathy [145], which could alleviate psychological distress and suicidal ideation [146]. Besides, those who were older generally held a more positive attitude toward suicide as they were more likely to accept, understand, and normalize suicide, in contrast to a study involving health professionals [147], which was likely due to desensitization with increasing clinical exposure toward suicide [148]. Meanwhile, our scoping review demonstrated those who were younger were less likely to comprehend suicide. Findings from other studies were ambiguous, highlighting a need for further exploration of this aspect [62,121].

In our review, personal exposure to suicide were associated with increased suicidal literacy, confidence in managing a person with thoughts of suicide, and reduced stigma as they were more likely able to empathize, understand and respect those with suicidal intentions [149]. Similar findings were discovered among healthcare professionals with personal and family history of mental illness [149].

4.1. Strengths and Limitations

This is the first scoping review available to provide a comprehensive overview of healthcare students’ knowledge of and attitude towards suicide at a global level. However, this review only included English studies, which might lead to language bias. Furthermore, the stringent search terms might have caused data loss. Most studies included used self-reported questionnaires, which predisposed the review to reporting bias based on social desirability. Given that 30% of the studies included were undertaken before the year 2013 and the cross-sectional design of the majority of studies, this review might not reflect the most contemporary knowledge of and attitude toward suicide.

4.2. Future Research and Recommendations

Considering that two thirds of suicides occur in developing countries,[1] and the underrepresentation of the studies from these countries in the review, more studies need to be conducted in these countries. Besides, more studies on students from other healthcare professions such as pharmacy and dentistry need to be conducted, as there is evidence of the role these professions could play in suicide prevention [150,151]. Despite the possible role of religiosity in affecting attitudes towards suicide [143,152,153,154], most studies in this review did not include this aspect in their results, hence the need for future studies to take this into consideration.

Furthermore, given the lack of knowledge and negative attitude among medical students, more studies should be conducted to address the contributing factors. Evaluation of medical curriculum should be undertaken to include relevant training programs that were shown to be effective to improve knowledge and attitude towards suicide. One study indicated that training community facilitators, including healthcare professionals, improved their knowledge, confidence, attitudes, and interventions when dealing with persons with thoughts of suicide [155]. In addition, a scoping review on suicide prevention programs found that training healthcare professionals and students improved their knowledge, behaviour, engagement in health services, as well as gatekeeper role outcomes [156]. Indeed, various studies have demonstrated the effectiveness of gatekeepers’ training programmes[157,158] in sessions as short as one hour,[159] educational interventions,[160] workshops [85], movies [89], simulations [161], and modules [90] in improving medical students’ knowledge and attitudes.

Specifically, gatekeepers’ training programmes have been widely applied among the public and have shown satisfactory and sustainable effectiveness [162,163] up until five months, in improving knowledge and skills in suicide prevention and intervention [109,111,163,164,165,166,167,168,169,170,171] and attitude [162,163,170] as evidenced by a systematic review [172]. Such programs should be organised and incorporated in medical curriculla, though further adaptations are still required to develop locally and culturally sensitive programmes [167,173]. Some examples with proven efficacy include Mental Health First Aid [174], Signs of Suicide (SOS) [175], Question, Persuade, and Refer (QPR) [96,110,111,163], Applied Suicide Intervention Skills Training (ASIST) [111], and Connect [109]. Studies have showed that medical staff who underwent ASIST, a 14 hour programme developed in Canada in 1983 with strong focus on training via simulations [176] possessed greater confidence in managing individuals with thoughts of suicide compared to other training programmes [111] as well as an increase in knowledge and positive attitude sustainable for years [176]. This was due to the fact that instead of referral to healthcare professionals as in other programs, it aimed to connect the individuals to community resources for suicide prevention and intervention [176].

5. Conclusions

Healthcare students showed a positive attitude in their role to treat and prevent suicide, and to support persons with thoughts of suicide. Medical students showed a relative lack of knowledge and more negative attitudes compared to nursing students, highlighting the need to evaluate current medical curriculum on suicide. The incorporation of gatekeepers’ training programmes into medical curriculla should be considered. Given the relative lack of data from developing countries and certain healthcare professions, future research should aim to address the current gaps.