Translation and validation of the Arabic version of the “Suicide Behavioral Attitude Questionnaire”

Abstract

Introduction : Attitudes and knowledge of health professionals are critical dimensions in the management of suicidal behavior. The “Suicide Behavioral Attitude Questionnaire” (SBAQ) was designed in Brazil to measure these variables in paramedical personnel.

Aim: To translate and validate the SBAQ in literary Arabic.

Methods : After author-approved translation and back-translation, the Arabic version of the SBAQ was distributed to 125 Tunisian caregivers working in psychiatric departments. Factor analysis and internal consistency were calculated. The stability was measured overtime using the paired Student’s T-test.

Results : Cronbach's alpha value was 0.741. The adequacy index of the factorization factor Kaiser-Meyer-Olkin (KMO) of our sample was 0.74. This value was higher than 0.5 which indicates that our data was suited for factor analysis. Bartlett’s sphericity test result was significant, rejecting the null hypothesis. Three factors were extracted explaining 50.7% of the overall variance. Cronbach's alpha value for the three subscales was 0.735, 0.713 and 0.798. The instrument had good stability over time.

Conclusions : The Arabic version of the SBAQ showed good reliability and validity allowing its use in Arabic speaking paramedical personnel.

Introduction

Suicide is a major public health problem around the world (1 ). The World Health Organization (WHO) estimates the global age-standardized suicide rate at 11.4/100000 and ranks suicide as the second leading cause of death among young people (2 ). Paramedical personnel are the first line of contact with the suicidal patient, and this close contact gives the encounter a central role in the management of these crisis situations (3 ). Attitudes towards suicide vary among different socio-cultural groups. Several scales have focused on the objective assessment of knowledge and attitudes towards suicide: the Suicide Opinion Questionnaire (SOQ), Suicide Attitude Questionnaire (SUIATT) and Attitudes Toward Suicide (ATTS) (4 ). The “Suicide Behavioral Attitude Questionnaire” (SBAQ), developed in 2005 in Brazil, is one of the rare instruments allowing the specific assessment of the attitude of paramedical personnel towards suicidal behaviors (5 ). It is a self-administered questionnaire including 21 items with responses on a visual analog scale. The assessment includes behavioral, cognitive and emotional aspects of suicide (5 ). In the English version three subscales are described: feeling towards the patient, professional capacity and right to suicide (5 ).

In the study of suicidal pathology, there are no validated psychometric tools in Arabic (4, 5, 6). This lack of instruments represents a pitfall for an objective study of suicide (4 ). The absence of validated tools in Arabic also concerns attitudes towards suicide. Thus, training in suicidal patients’ management lacks a benchmark for identifying the educational needs of the target population. Valid tools would also allow measurement of changes in attitudes at the end of training sessions (7, 8). The SBAQ has been previously translated and validated in Italian (9 ) and Swedish (10 ).

The objective of this study was first to translate the SBAQ into literary Arabic and then to validate the translated version in a population of Tunisian caregivers.

Methods

Study design

This study is a scale transcultural adaptation conducted over the period between March 2019 and July 2019. It consisted of two parts. The first was the translation of the scale from English to Arabic. The second was the validation of the translated version. Translation of SBAQ followed the international recommendations in this field (11 ). The Arabic SBAQ version development followed the translation/back-translation method. The English version has been translated into Literary Arabic by two different translators. After a step of reconciliation of the two translated versions, the final one was reviewed and approved by developers of the original scale (Appendix A). The validation part also included two phases, a cross-sectional and descriptive phase of instrument adaptation and a prospective phase concerning the stability over time. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008 (12 ). The study was approved by the Ethics Committee of Razi Hospital. Informed consent was obtained from each subject.

Research Tool

The SBAQ is an English validated self-administered psychometric tool, which was developed in 2005 in Brazil by Botega et al. (5 ). The final version of the SBAQ is composed of 21 items to be answered by the participant using a visual analogue scale. The approximated time to complete the SBAQ is fifteen minutes. Factor analysis of the original version showed three subscales corresponding to three dimensions of attitudes towards suicide: 1- feelings towards a suicidal patient (7 items) 2- professional capacities towards suicide (4 items) 3- right to suicide (5 items). Five items did not belong to any dimension. The total score is obtained by addition of the 21 items of the scale. The score for each dimension is the algebraic sum of the scores of the items in the related subscale. There is no threshold for this questionnaire (5 ).

Subjects

After the author’s approval, the translated version of the SBAQ was distributed to 137 caregivers working in six different Tunisian psychiatry departments of the Razi Hospital. Nurses and healthcare assistants took part in the study. A minimum of six months of professional experience was required. Questionnaires completed in a manner inconsistent with the visual analog scale format were excluded.

There is no consensus regarding the number of subjects to include in a cross-cultural validation study (13 ). The majority of authors have commonly accepted a number of 5 subjects per item or a sample size of at least 100 (13, 14). Considering the 21 items of the SBAQ, we set our sample size at 125 subjects.

Data Analysis

The reliability of the instrument was assessed by measuring the internal consistency via the Cronbach’s alpha coefficient. The stability over time was measured by means of paired Student’s T-test on a group of 5 participants after an interval of three months.

The sampling adequacy was evaluated using the Kaiser-Meyer-Olkin (KMO) test, where values > 0.7 are considered good (15 ). Bartlett’s sphericity test was used to examine the null hypothesis that the variables were not correlated in the population (p < 0.05) (15 ). Construct validity was estimated by factor analysis of different items. For the exploratory factor analysis, we followed the same statistical procedure used by the SBAQ developers, Maximum likelihood and Varimax orthogonal rotation with three factors solution, the eigenvalue was calculated using scree plot method (15 ). Items with the highest loading (>0.40) were used to interpret factors.

Results

The socio-demographic and clinical variables of the healthcare population are presented in Table 1 .

Table1. The socio-demographic and clinical variables of thesample (n=125).

Variable	N	mean ± SD or %
Age	125	33 ± 0.52
Female	55	53%
Personal medical history of a mental disorder	14	11.2%
History of suicide attempt	6	4.8%
Function Nurse Care assistant	93 32	74.4% 25.6%
Length of service (years)	125	12.2 ± 0.47
Assistance to a person with suicidal thoughts:	97	77.6%

SD: Standard deviation.

Structure validity

The three extracted factors with Varimax orthogonal rotation explained 50.7% of the overall variance (Table 2 ). The Eigenvalue of the three-factor solution chosen in our questionnaire was 2. The Kaiser-Meyer-Olkin (KMO) factorization adequacy index of the sample was 0.74. The results of the factor analysis are significant if the KMO value is higher than 0.5, which is the case in our sample. The result of the Bartlett’s sphericity test was significant (p<0.0005), rejecting the null hypothesis.

Table2. Translated SBAQ and original SBAQ factorial sub-scalesand item loadings on each factor.

	Item	Translated SBAQ factors				Original SBAQ factors
		1	2	3	1		2	3
Factor 1: Feeling towards the patient	2	0.44	0.02	0.01	0.49		0.06	0.06
	5	0.57	-0.27	-0.12	0.59		-0.12	-0.10
	9	0.56	-0.07	-0.24	0.45		0.07	0.02
	13	0.49	-0.01	0.15	0.48		0.06	0.03
	15	0.45	-0.12	-0.02	0.54		-0.27	0.01
	19	0.41	-0.23	0.15	0.48
Factor 2 : Professional capacity	1	0.13	0.67	0.13	-0.02		0.58	0.06
	7	-0.02	0.64	-0.04	0.01		0.53	-0.01
	10	-0.01	0.54	0.10	0.12		0.58	-0.16
	12	0.20	-0.29	0.19	0.16		-0.38	0.08
Factor 3 : Right to suicide	3	0.08	-0.06	-0.51	0.40		0.17	-0.49
	4	0.36	0.36	0.38	-0.02		0.17	0.39
	6	0.07	0.23	0.62	0.15		-0.05	0.6
	17	-0.06	0.08	-0.25	0.39		0.14	-0.27
	18	0.01	0.09	0.41	0.07		0.04	0.43
	21	0.30	0.14	-0.10	0.08		0.06	-0.14
Items not included in the factorial sub-scales (in the Arabic version).	8	-0.16	0.21	0.13	0.31		0.20	-0.05
	20	0.19	0.20	-0.04	0.31		0.10	0.05
	11	0.26	0.17	-0.14	0.30		0.01	-0.03
	14	0.17	0.03	-0.03	0.01		0.29	0.18
	16	0.15	0.03	0.08	0.24		0.05	0.38

SBAQ: Suicide Behavioral Attitude Questionnaire.

Reliability

Cronbach's alpha value was 0.741. Cronbach's alpha values for the three subscales of the Arabic version of the SBAQ were: feeling towards the patient (0.735), professional capacity (0.713) and right to suicide (0.798).

Stability over time

The mean scores calculated for each subscale in a sample of 5 subjects between T0 and T1 separated by three months were compared using Student's T-test. The significance level of p for all three subscales was superior to 0.05, not significant. Our hypothesis has been confirmed, indicating a good stability of the instrument over time.

Discussion

In this work, we developed an Arabic version of the SBAQ, which respected a semantic and conceptual equivalence to the original version. This equivalence was attested by the original author of the questionnaire. The validation process made it possible to prove the reliability of the instrument on the one hand by its good internal consistency and on the other hand by its temporal stability during test-retest assessment. Throughout this process, we were also able to judge the structural validity with results of the factorial analysis similar to that of the original version respecting the distribution of the items in 3 main dimensions.

Several questionnaires have been developed to objectively measure and judge the attitude towards suicide (4 ). The Self-Objectification Scale (SOQ) and the Suicide-Attitude (SUIATT) questionnaires focused on attitudes towards patients who have already committed suicide. According to several critics, these tools had non-determining psychometric characteristics (4, 16). The Understanding of Suicide Attempt Patient Scale (UPS) was developed by Samuelsson et al in 1997 to assess the attitudes of psychiatric nursing personnel towards patients who have attempted suicide (17 ). Although having good psychometric properties, it was limited to measuring attitudes and neglected cognitive and behavioral dimensions (4 ). The SBAQ was developed in 2005, in Brazil, due to the practical and theoretical limitations of these tools (16, 17, 18). This instrument was chosen because it measures attitudes in their cognitive, affective and behavioral components (5, 19). Moreover, the SBAQ has the advantage of being short and easy to complete.

Inhere, the original version has been translated into Literary Arabic by two different translators. This step had to be carried out by at least two translators, and opinions diverged on the criteria for choosing the translators (20). According to the WHO, the instrument had to be translated back into English by an independent translator, whose mother tongue is English and who has no information about the instrument in question (11). Regarding the reliability, Cronbach's alpha values for all three dimensions were superior to 0.7, indicating that the translated questionnaire had acceptable internal consistency (21). Relatively low values were frequently observed in attitude scales (22). In addition, the value of Cronbach's alpha increased as the number of items on a scale increased (21). Factor analysis indicated that the Arabic version of the SBAQ had a very similar three-factor structure to the original scale (5). The adequacy index of the factorization factor KMO of our sample was 0.74, which could be qualified as acceptable (23). Bartlett’s sphericity test result was significant (p<0.0005), rejecting the null hypothesis. The test-retest of the three subscales indicated good temporal stability of the Arabic version. The SBAQ had not been subject to a test-retest in its original English version (5).

The study of attitudes toward suicide is an important aspect in the training of health care personnel (7, 8). Training is a crucial step in the struggle against suicide (24 ). This action represents a major public health challenge (25 ). The availability of attitude measurement tools gives objectivity to the targeted training (26 ). The SBAQ in its original version and in its translated versions has served this purpose (5 ). Thus, in a Brazilian study, the SBAQ was used to assess the effect of an educational intervention on the attitudes of healthcare workers towards patients with suicidal behavior (27 ). The intervention group was compared before and after training, and compared to a control group. A statistically significant difference was noticed in the three domains of the scale. An Italian validated version of the SBAQ was utilized to measure the changes in attitudes towards suicide before and after an educational session provided to nursing students (9, 28). The assessment shows an improvement in the score regarding the domain "Professional ability" (28 ). These results highlight the usefulness of the SBAQ in refining training sessions in accordance with the targeted population. This tool can be used in such purposes in Tunisian academic and professional educational sessions.

In the view of these results, it appears that the Arabic version of the SBAQ is a valid and reliable tool for the study of the nurses' attitude towards caring for the person with suicidal ideation. Regarding the limitations of the study, the population included was exclusively psychiatric paramedical staff, and we are, therefore, unable to extend the results to all caregivers in different specialties. The sample size of 5 participants involved in the test-retest is low. However, there is no recommendation to set this number. The discriminant validation was not carried out during this work due to the unavailability of other instruments for the measurement of convergent and divergent validity. The SBAQ's original version was validated in a Brazilian population with cultural specificities, mainly the religious one. Two items (item2 and item6) of the SBAQ are related to religious beliefs. In this study we did not measure the degree of religiosity of our sample. Further studies are needed to investigate the sensitivity of the Arabic version of the SBAQ in capturing specificities of attitudes toward suicide in an Arab-Muslim population.

Conclusions

At the end of this procedure, the of the SBAQ was translated and validated in Arabic. This instrument can be used in training courses and awareness campaigns for paramedical personnel in order to optimize the management of suicidal behavior.

Appendix

The Arab version of the “ Suicide Behavioral Attitude Questionnaire”

1- أشعر بنفسي قادراً على مساعدة شخص حاول الانتحار

Feel capable of helping a person who attempted suicide

2- الشخص الذي يهدد بالانتحار بشدة عادة لا يقتل نفسه

Who frequently gives forewarns usually does not kill oneself.

3- رغم كل شيء أظن أن الشخص الذي يرغب بقتل نفسه له الحق في ذلك

Despite everything I think that of a person wishes to kill him/herself, he/she has the right to do it.

4- أمام حالة انتحار أظن لو أن أحداً تحدث إلى الشخص لكان وجد سبيلاً أخر

When facing a suicide I think: if somebody had talked to the person, he/she

would have found another way.

5- بصراحة أفضل أن لا اتدخل مع المرضى الذين حاولوا الانتحار

Honestly, I prefer not to get involved with patients who attempted suicide.

6- الحياة هدية من الله ولذا هو وحده قادر على استرجاعها

Life is God’s gift, therefore only He can take it back.

7- أشعر انني قادر على التفطن لمريض معرض لخطر الانتحار

feel I am capable of perceiving when a patient is under the risk of suicide.

8- بصفة عامة ضحايا الانتحار لديهم اضطراب عقلي

In general, suicide victims have a mental disorder.

9- أخشى أن أسأل حول أفكار الانتحار فينتهي بي الأمر أن أحمل المريض على ذلك

I am afraid of asking about suicide ideas and end up inducing the patient to it.

10- امتلك مهارات مهنية للإحاطة بمرضى معرضين لخطر الانتحار

Have professional skills to handle patients under the risk of suicide

11- أظن أن الفرد يحتاج شجاعة لقتل نفسه

Think that one needs courage to kill him/herself

12- أحس بعدم الأمان حين اعتني بمريض تحت خطر الانتحار

Feel insecure to care for patients under suicide risk

13- أحياناً أغضب لأنه يوجد العديد من الناس الذين يرغبون في العيش وذاك المريض يرغب في الموت

I sometimes get angry because there are so many people who want to live, and that patient wants to die.

14- إذا أقترح عيادة طب نفسي على مريض تحدث حول قتل نفسه أظن أن الطبيب المباشر سيتقبل ذلك

If I suggest psychiatric consultation for a patient who talked about killing him/herself, I think that this will be accepted by the physician.

15- يشعر الفرد بالعجز إزاء شخص يريد أن يقتل نفسه

One feels impotent towards a person who wants to kill him/herself.

16- الشخص الذي يكون الله في قلبه لا يحاول الانتحار

The person that has God in his/her heart will not attempt suicide.

17- بالنسبة للمرضى الذين يتألمون كثيراً بسبب مرض أظن أن فكرة الانتحار مقبولة أكثر

In the case of patients who are suffering a lot due to a disease, I think the idea of suicide is more acceptable.

18- حين يتحدث شخص على ارتكاب إنتحار أحاول أن أغير رأيه

when a person talks about committing suicide, I try to change him/her mind.

19- الشخص الذي يريد حقاً قتل نفسه لا يقوم بـ"محاولة"  إنتحار

The person who really wants to kill him/herself does not “attempt” suicide.

20- المرضى المقيمون نادراً ما يقتلون أنفسهم بدون وجود سبب شديد لذلك

Inpatients rarely kill themselves without having a strong reason for that.

21- وجدت نفسي في مواقف جعلتني أفكر في قتل نفسي

Have been through situations that made me think about killing myself

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