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Validation and psychometric properties of Suicide Behaviors Questionnaire-Revised (SBQ-R) in Iran
Journal Pre-proof Validation and Psychometric Properties of Suicide Behaviors Questionnaire-Revised (SBQ-R) in Iran Mohammadali Amini-Tehrani, Mohammad Nasiri, Tina Jalali, Raheleh Sadeghi, Amene Ghotbi, Hadi Zamanian
PII:
S1876-2018(19)30728-2
DOI:
https://doi.org/10.1016/j.ajp.2019.101856
Reference:
AJP 101856
To appear in:
Asian Journal of Psychiatry
Received Date:
8 August 2019
Revised Date:
27 September 2019
Accepted Date:
21 October 2019
Please cite this article as: Amini-Tehrani M, Nasiri M, Jalali T, Sadeghi R, Ghotbi A, Zamanian H, Validation and Psychometric Properties of Suicide Behaviors Questionnaire-Revised (SBQ-R) in Iran, Asian Journal of Psychiatry (2019), doi: https://doi.org/10.1016/j.ajp.2019.101856
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.
Validation and Psychometric Properties of Suicide Behaviors Questionnaire-Revised (SBQR) in Iran
Mohammadali Amini-Tehrania,b, Mohammad Nasiria, Tina Jalalib, Raheleh Sadeghib, Amene Ghotbib, Hadi Zamanianc,b*
Department of Psychology and Education, University of Tehran, Tehran, Iran
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Health Psychology & Behavior Medicine Research Group, Students Scientific Research Center,
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Tehran University of Medical Sciences, Tehran, Iran. Qom University of Medical Sciences, Qom, Iran.
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Corresponding Author: Hadi Zamanian, MD, PhD in Health Education and Promotion, School
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of Health, Qom University of Medical Sciences, Lavasani St., Qom, Iran. Tel: +983713649373, Fax: +9837706470, Postal Code: 3713649373, Email: [email protected],
Highlights
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[email protected], Mobile: +989123543893
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Research on suicide in Iran lacks comprehensive assessment tools, beyond Ideations Suicide Behavior Questionnaire-Revised shows sound reliability and validity The suicide-related behaviors and risk of Iranian undergraduates were notable Female students had a higher score in terms of different suicide-related behaviors
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Abstract Background: Suicide is increasing in young Iranian population, which necessitates the
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employing of valid, yet abridged instruments assessing the constellation of suicide-related
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behaviors. The study aimed at validating Suicide Behavior Questionnaire-Revised (SBQ-R) among Iranian undergraduates.
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Methods: A total of 487 undergraduates were surveyed in 2018. Construct validity of SBQ-R
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was examined via confirmatory factor analysis (CFA), and Spearman’s correlation with two single-item indices of suicide acceptability (SA) and lifetime suicidal ideation (LSI) was determined. Logistic regression and Kruskal-Wallis tests were used to examine the cut-off points
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(≥ 7 and ≥ 8) and categorizations as per item 1.
Results: The mean SBQ-R score was 5.79±3.55. Cut-off points ≥ 7 and ≥ 8 categorized 150 (30.8%) and 123 (25.2%) samples with suicide risk, respectively. Women obtained significantly
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higher scores on all indices, except items 1 and 4. CFA confirmed the model with sound goodness-of-fit, with factor loadings of 0.70 to 0.83. Composite reliability and average variance extracted were 0.87 and 0.63, respectively. The SBQ-R’s correlation with SA and LSI confirmed its concurrent validity. Regression analysis confirmed the ability of both cut-off points to distinguish the participants with high SA and LSI; however, the cut-off point ≥ 8 produced better
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results regarding high LSI. Based on item 1, normal versus low- and high-risk samples were significantly different in terms of SA, LSI, and adjusted total score of SBQ-R (P< 0.0001). Conclusion: SBQ-R is an economic and psychometrically sound tool, which can be utilized to identify suicide-related behaviors and risks in young Iranian population. Keywords: Assessment; Confirmatory Factor Analysis; Suicide; SBQ-R; Validation
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Introduction Suicide and its associated factors are critical global issues, affecting different domains of life,
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regardless of culture, nation, religion, gender, or social class. Approximately one million people die by suicide every year worldwide, with China and India accounting for almost 50% of the
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overall suicide rate (Mann, 2002). Although under-reporting of suicidal ideation and behavior is
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highly likely in the Iranian population, the prevalence of suicidal thoughts, plans, and attempts has been estimated at 12.7%, 6.2%, and 3.3%, with incidence rates of 5.7%, 2.9%, and 1%,
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respectively (Malakouti et al., 2009). According to some studies, young Iranian people, aged 1524 and 25-34 years, constitute a large proportion of suicide attempters, with 48% and 32.5%,
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respectively (Mirahmadizadeh et al., 2019). Also, the growing rate of suicidal attempts and deaths during the past decades indicate the increased risk of suicidality in Iran (HassanianMoghaddam & Zamani, 2017; Mirahmadizadeh et al., 2019). Suicide-related behaviors have been also reported as a major issue among university students (Katsumata et al., 2017; Mortier et
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al., 2018).
Silverman et al. (2007a) developed a uniform terminology for suicide-related behaviors,
including suicidal ideations, communications (suicide threats and plans), attempts, and suicide, which require the intention to die. Therefore, to determine the suicide risk in a given population, appropriate scales are expected to incorporate different dimensions of suicide-related behaviors. 3
The Suicide Behaviors Questionnaire-Revised (SBQ-R) has been used in many studies to evaluate suicidal thoughts, plans, communication, attempts, and risks, which address the individual’s deadly intent (Osman et al., 2001). Osman et al. (2001) designed SBQ-R based on an original work of Linehan and Nielsen (1981). This shortened scale contains four items on suicidal behaviors and ideations over the past
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12 months, suicide-related communication, and self-reported likelihood of any future suicidal behavior. The total score of SBQ-R ranges from 3 to 18, with higher scores indicating a higher
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risk of suicide (Osman et al., 2001). Osman et al. (2001) validated this instrument in four groups of adolescent psychiatric inpatients, high school students, adult psychiatric inpatients, and
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undergraduates. They found that scores ≥ 7, with a sensitivity of 0.93 and specificity of 0.95,
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could indicate the risk of suicide in the general adult population (Osman et al., 2001). SBQ-R has been approved as a useful scale for suicide risk assessment in clinical and non-clinical samples
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(Ghasemi et al., 2015). It has also been employed in different populations (Aloba et al., 2017; Glaesmer et al., 2018; Lund et al., 2017).
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Although this instrument was translated in an unpublished study by Safa and Boroujerdi (Safa et al., 2014) and applied in an Iranian population (Shakeri et al., 2015), there is no report of its validity or reliability. Suicide research in Iran has been focused on suicide attempts (Mokhtari et al., 2019), while there is a crucial need for more investigation on different psychological,
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interpersonal, social, and cultural contributing factors to the issue. Besides, employing valid and reliable, yet short instrument is fundamental to behavioral research. Therefore, in the present study, we aimed to evaluate the construct validity, concurrent validity, internal consistency, and applicability of SBQ-R in Iranian students.
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Methods Design and sampling The present study was conducted during April-May 2018 as part of “Suicidality-RP Factors Project.” An institutional board reviewed the study protocol and the Iranian National Committee for Ethics in Biomedical Research approved the study. The sample was university
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undergraduates, within the age range of 18-29 years. Informed consent was obtained. Sampling was carried out in an Iranian university among students from three educational fields of
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humanities (five schools), engineering (one school), and basic sciences (two schools). A total of 524 booklets were distributed in classrooms in sealed envelopes to ensure confidentiality during
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data collection. However, 33 booklets were incomplete, one participant graduated from the
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university during the study, and three participants were unwilling to answer suicide-related questions. Finally, 487 booklets were studied in the final analysis (response rate: 92.9%).
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The age range of the participants was 19-28 years (20.66±1.42). The majority of the participants were female (n=288, 59.2%). Also, the majority were studying humanities (n=254,
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52.2%), followed by engineering (n=124, 25.5%) and basic sciences (n=109, 22.4%). In terms of ethnicity, most of the participants were Fars (n=262, 53.8%), followed by Turk (n=113, 23.2%), Mazani/Gilak (n=40, 8.2%), Lor (n=21, 4.3%), Kurd (n=14, 2.9%), and other ethnicities including Baluch, Arab, and Turkman (n=15, 2.1%). The samples mostly lived with their
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families (n=326, 66.9%) or in university dormitories (30.2%, n=147). Also, most of them were single (n=466, 95.7%). Concurrent validity measurements Suicide acceptability (SA) was measured as a single-item index. The participants completed the following statement: “Some argue that suicide is the right choice for an individual, as a remedy 5
from pain, misery, and suffering. In your opinion, suicide is…” The participants completed the statement on a five-point Likert scale (“completely unacceptable,” “mostly unacceptable,” “no opinion,” “mostly acceptable,” and “completely acceptable”). Some previous studies have reported that a permissive attitude towards suicide can be a risk factor for suicidal ideation (Kodaka et al., 2013). Therefore, we hypothesized that SA has a positive relationship with the
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scale items and total score (H1). We also hypothesized that students, who agreed with suicide as an acceptable option, would be exposed to a higher risk of suicide, as measured by SBQ-R (H2).
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Besides, lifetime suicidal ideation (LSI) was measured as a single-item index. The
participants answered the following question: “Have you ever seriously thought about taking
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your own life?” The responses included: “never” (score 0), “once” (score 1), “a couple of times”
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(score 2), and “several times” (score 3). We hypothesized that LSI has a positive relationship with the scale items and total score (H3). We also hypothesized that a higher LSI would increase
Data analysis
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the risk of suicide (H4).
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Descriptive statistics were measured to report the frequency of suicide-related behaviors and the mean score of the study sample. Construct validity was examined using confirmatory factor analysis (CFA) with robust maximum likelihood (MLR) in Mplus software (Muthen & Muthen, 1998-2012). MLR is considered suitable for data without a normal distribution, yielding
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maximum likelihood estimations with robust standard errors (Suh, 2015). We used composite reliability (CR> 0.70) as an index of internal consistency and the average variance extracted (AVE> 0.50) as an index of variance explained by the measurement model to evaluate the validity of the latent construct (Hair et al., 2010). Moreover, Cronbach’s alpha coefficient (>
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0.70) was measured, and Spearman’s correlation coefficient (rho) was determined for the correlational analysis of SA and LSI with SBQ-R items and total SBQ-R score. Two further steps were incorporated to examine the applicability of SBQ-R. First, univariate logistic regression was used to investigate how SBQ-R cut-off points ≥ 7 and ≥ 8, as indicators of suicide risk, would be applicable relative to SA and LSI. The dummy variable of
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suicide risk (1= total score ≥ 7, 0 = total score < 7) was entered in the model as the dependent variable. LSI was also included as an independent categorical variable with reference to the
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lowest category (i.e., “never”). On the other hand, SA was transformed into a dichotomous
variable with low (score: 1-3) and high (score: 4-5) acceptability; score 1 indicated the person’s
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favoring of SA (FSA).
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Both LSI and FSA were simultaneously entered in the model as independent variables. Second, SBQ-R item 1 was used for categorization of normal (“never” and “a brief passing
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thought”), low suicide risk (“plan” with and without intention to die), and high suicide risk (“attempt” with and without intention to die) groups. We hypothesized that there would be a
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significant difference between the groups in terms of the adjusted total score of SBQ-R (sum of SBQ-R items 2-4), SA, and LSI (H5).
Kruskal-Wallis test was used for multiple group comparisons. Data analysis was carried out in SPSS V. 24 (IBM Inc., USA) and Mplus V. 7.4 (15). P-value < 0.05 (95% CI) was considered
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statistically significant. Results
Suicide-related behaviors The mean (standard deviation) scores of SBQ-R items were 1.69±1.10, 1.56±.77, 1.39±.67, and 1.16±1.60, respectively, with a total score of 5.79±3.55 (range: 3-18). The mean score of SA was 7
2.24±1.30, and the mean score of LSI was 1.81±1.15. Table 1 presents the detailed pattern of responses to SBQ-R items, SA, and LSI. As shown in Table 1, there was a significant difference between male and female students in terms of SBQ-R2, SBQ-R3, suicide risk, SA, and LSI; in other words, female students obtained higher scores than their male counterparts. These rates were discussed in another publication on this dataset (ANONYMOUS), and they are reported
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here as sample description. Construct validity and reliability
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CFA indicated that the model fit the data well (Chi-square= 0.682; DF= 2; P= 0.711; GFI=
0.999; CFI= 1.0; TLI= 1.0; RMSEA= 0.00; 90% CI= [0.0, 0.065]; PCLOSE= 0.897). Factor
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loadings (standard error) for items 1 to 4 were 0.831 (0.026), 0.827 (0.025), 0.697 (0.038), and
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0.799 (0.028), respectively (P< 0.00001). CR (0.869), AVE (0.625; 63% of total variance), and Cronbach’s alpha (0.82) confirmed the internal consistency and variance explained by the latent
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construct. Convergent and divergent validity
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According to Spearman’s correlation coefficients presented in Table 2, SA and LSI had significant positive relationships with SBQ-R items and the total score (P< 0.0001). The results confirmed hypotheses H1 and H3, indicating the concurrent validity of SBQ-R. Applicability of SBQ-R
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Table 3 presents the results of logistic regression analysis. Regarding the cut-off point ≥ 7, our results indicated that the suicide risk increased significantly by FSA (12.18; 95% CI= [6.96, 21.13]). Also, with “no LSI” as the reference category, categories of “once” (8.25; 95% CI= [3.70, 18.41]) and “a couple of times” (17.29, 95% CI= [7.95, 37.62]) were associated with a significant increase in suicide risk. On the other hand, despite the increased risk of suicide (1.48) 8
associated with the category of “several times,” no significant difference was observed (95% CI= [0.73, 3.0]). These results were also true for the cut-off point ≥ 8. This cut-off point could also differentiate samples, who selected the category of “several times” (OR= 2.24; 95% CI= [1.07, 4.66]). Therefore, our hypotheses (H2 and H4) regarding the applicability of SBQ-R cut-off points in Iranian students were confirmed.
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Regarding item 1, the results of Kruskal-Wallis test showed significant differences between the three subgroups of normal, low suicide risk, and high suicide risk in terms of the
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adjusted SBQ-R score (df= 2; test statistics= 198.547; asymptotic P< 0.0001), SA (df= 2; test statistics= 95.481; asymptotic P< 0.0001), and LSI (df= 2, statistics= 70.530, asymptotic P<
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0.0001). Also, pair-wise comparisons indicated significant differences between the normal and
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low-risk groups (adjusted P< 0.0001), as well as the normal and high-risk groups (adjusted P< 0.0001) in terms of all three indices; however, the difference was insignificant between the low-
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and high-risk groups (adjusted P= 0.496 for adjusted total score; adjusted P= 0.237 for SA; and adjusted P= 0.815 for LSI); therefore, hypothesis H5 was also confirmed.
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Discussion
Although many researchers have continuously reported suicide-related issues in Iranian populations, especially young people, no comprehensive, yet economic scale has been introduced to assess the broad range of suicidal behaviors. SBQ-R presents a short, suitable instrument,
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which can be incorporated into research on suicidality in different populations. Although the scale was previously translated by Safa and Boroujerdi (Safa et al., 2014), there is no detailed information about its validity and psychometric properties. Therefore, in the current study, we aimed to examine the validity, reliability, and applicability of SBQ-R in an Iranian sample of undergraduates. 9
CFA confirmed the unidimensionality of SBQ-R. The results indicated quite sound goodness-of-fit of the model, along with strong factor loadings, which explained a valid proportion of variance in the latent construct (Hair et al., 2010). Some recent studies have also confirmed the construct validity and unidimensionality of SBQ-R, based on CFA (Campos & Holden, 2019; Glaesmer et al., 2018). Also, the current study indicated the concurrent validity of
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this scale, considering its significant positive relationship with lifetime suicide ideation (LSI) and, in particular, suicide acceptability (SA) (Kodaka et al., 2013). Generally, assessment of
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suicide risk requires the evaluation of a constellation of suicide-related behaviors, including
suicidal ideations, communications, plans, and attempts, which are suggested as constitutive
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aspects of suicide risk (Silverman et al., 2007a, 2007b). According to these findings, SBQ-R, as
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a short scale of essential suicide-related behaviors, can be used to assess the valid construct of suicide risk.
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Internal consistency of SBQ-R was also acceptable, with composite reliability of 0.86 for the latent construct in CFA (Hair et al., 2010) and Cronbach’s alpha of 0.82. In this regard, a
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study by Osman et al. (Osman et al., 2001) reported a Cronbach’s alpha coefficient of 0.88. Furthermore, validation studies have reported a Cronbach’s alpha of 0.77 for people with and without disability (Lund et al., 2017), 0.72 for German adults (Glaesmer et al., 2018), and 0.69 for Portuguese undergraduates (Campos & Holden, 2019). Since internal consistency is a unique
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feature of each study sample (Tavakol & Dennick, 2011), these consistent results indicate the inter-relatedness of the four items of the scale in various populations. Our investigation of the applicability of cut-off points (≥ 7 and ≥ 8), as suggested by
Osman et al. (2001), revealed that both cut-off points could significantly predict SA and LSI. However, the cut-off point ≥ 8 showed higher accuracy in differentiating the category of “high 10
LSI.” Some recent studies have confirmed the validity of the cut-off point ≥ 7 in distinguishing suicide attempters from non-attempters, with a sensitivity of 0.89 and specificity of 0.82 (Campos & Holden, 2019). Also, the first item of the scale could differentiate between normal (score 1) and clinical (scores 2 and 3) groups in terms of SA, LSI, and adjusted total score of SBQ-R.
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In line with the results of the original study by Osman et al. (2001), we found that SBQ-R could reliably address suicide risk in young populations, particularly undergraduates. Some
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scholars argue that suicide risk assessment is far beyond a simple analysis using structured or semi-structured tools, given the importance of suicidal intentions and the ultimate goal of health
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professionals, which is to reduce the risk of suicide (Simon, 2012). According to Murray
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(Murray, 2016), since suicide risk assessment (i.e., prediction) aims at identifying individuals at risk of actual death, the high rate of false-negative and false-positive diagnoses, represented by
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suicide categorizations (e.g., high suicide risk), may prevent adequate care and support for these patients.
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Conversely, some experimental studies suggest that suicide, at least at cognitive levels (i.e., thoughts and ideations), can indicate a low desire for life rather than a desire for death (Harrison et al., 2014). This notion is consistent with the results of some recent studies, which have revealed the importance of one’s meaning-focused coping strategies in the face of adverse
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life events (Wang et al., 2019). Moreover, the suicidal tendencies of a university student can affect his/her peers (Ash, 2012) and increase the risk of low academic performance in the early years of university (Mortier et al., 2015). Insofar as the suicidal tendency is an important indicator of an undesirable life, reduced well-being, and low performance, future research may benefit from suicide assessment tools to identify individuals at risk of suicide. 11
This study was performed on a student population, selected from one single university; therefore, the results cannot be generalized to all populations of Iran. Future studies can include a validation analysis of SBQ-R in psychiatric inpatient populations to investigate its performance in terms of criterion validity, test-retest reliability, and cut-off points in Iranian people. Also, the use of single-item measures for the evaluation of concurrent validity can be argued, especially
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concerning the validity and accuracy of construct measurements. Nevertheless, our findings are consistent with the available information in the field, which suggests SBQ-R applicability in
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different populations. Conclusion
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SBQ-R is an economic and psychometrically sound instrument, which can be incorporated into
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public health, health psychology, and clinical psychology studies to identify suicide-related behaviors in different populations. Also, this abbreviated scale can be useful in experimental
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research on the development, expansion, and re-evaluation of suicide theories (Gunn & Lester,
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2015), which seems essential in Iran.
Authors Contributions
MAT contributed to conceptual design, statistical analysis, data gathering, and finalizing the
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manuscript. MN, TJ, and RS contributed to data collection. AG contributed to statistical analysis and provision of the original draft. HZ contributed as the supervisor in conceptual design and as the corresponding author.
Conflict of Interest 12
Authors declare that there is no conflict of interest regarding any aspects of the publication of this article.
Financial Disclosure MAT as the master student of University of Tehran, Iran, received partial grant for conducting
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the project.
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Conflict of Interest
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Authors declare that there is no conflict of interest regarding any aspects of the publication of this article.
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doi:10.1080/10705511.2014.937669
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Tavakol, M., & Dennick, R. (2011). Making sense of Cronbach's alpha. International Journal of Medical Education, 2, 53-55. doi:10.5116/ijme.4dfb.8dfd
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Wang, Y., Lippke, S., Miao, M., & Gan, Y. (2019). Restoring meaning in life by meaning-focused
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coping: The role of self-distancing. Psych J. doi:10.1002/pchj.296
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Figure 1. Confirmatory factor analysis of SBQ-R with MLR estimator, modelled by Mplus (Muthen & Muthen, 2012). The factor loadings (standard error) are standardized estimations (p <.00001). Chi-square = 0.682, DF = 2, p= .711, GFI = .999, CFI = 1.0, TLI=1.0, RMSEA = .00,
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90%CI= [.0, .065], PCLOSE= .897. Composite reliability (CR) = .869. Average variance extracted (AVE) = .625.
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Table 1. Frequency of Suicide-related Behaviors ( N = 487) Female Students (n = 288)
n (%)
SBQ-R1 Never
287 (58.9)
123 (64.4)
162 (56.3)
A brief Passing thought
141 (29.0)
54 (28.3)
83 (28.8)
A plan without trying
33 (6.8)
6 (3.1)
25 (8.7)
A plan with intention to die
14 (2.9)
4 (2.1)
10 (3.5)
Attempt with no intention to die
4 (0.8)
3 (1.6)
1 (0.3)
Attempt with intention to die
8 (1.6)
1 (0.5)
SBQ-R2 Never
306 (62.8)
Rarely
97 (19.9)
Sometimes
37 (7.6)
re 38 (19.9)
40 (13.9)
11 (5.8)
22 (7.6)
25 (5.1)
4 (2.1)
23 (8.0)
22 (4.5)
12 (6.3)
11 (3.8)
347 (71.3)
149 (78.0)
178 (61.8)
One time, no intention to die
64 (13.1)
23 (12.0)
56 (19.4)
One time , with intention to die
26 (5.3)
4 (2.1)
25 (8.7)
More than once, no intention to die
35 (7.2)
12 (6.3)
19 (6.6)
3 (1.6)
10 (3.5)
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192 (66.7)
SBQ-R3 No
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Very Often
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More than once , with intention to 15 (3.1) die SBQ-R4 Never
270 (55.4)
111 (58.1)
157 (54.5)
No chance at all
59 (12.1)
25 (13.1)
33 (11.5)
Rather Unlikely
63 (12.9)
27 (14.1)
33 (11.5)
Unlikely
31 (6.4)
10 (5.2)
20 (6.9)
19
.076
12.043 [5]
.034
11.321 [4]
.023
8.343 [6]
.214
7 (2.4)
126 (66.0)
Often
pvalue
8.454 [4]
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Variables
Chi-square [df]
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Male Students (n = 191)
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Total sample (N = 487)
44 (9.0)
11 (5.8)
33 (11.5)
Rather Likely
11 (2.3)
2 (1.0)
8 (2.8)
Very Likely
9 (1.8)
5 (2.6)
4 (1.4)
Suicide risk ≥7
150 (30.8)
48 (25.1)
98 (34.0)
4.29 [1]
.038
≥8
123 (25.3)
35 (18.3)
84 (29.2)
7.230 [1]
.007
SA Completely unacceptable
215 (44.3)
101 (53.4)
112 (38.9)
Mainly unacceptable
76 (15.7)
28 (14.8)
47 (16.3)
No opinion
72 (14.8)
25 (13.2)
45 (15.6)
Mainly acceptable
109 (22.5)
30 (15.9)
76 (26.4)
Completely acceptable
13 (2.7)
5 (2.6)
8 (2.8)
302 (69.0)
134 (70.2)
166 (57.8)
47 (9.7)
9 (4.7)
35 (12.2)
63 (13) 74 (15.2)
.02
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11.707 [4]
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Never Once A couple of times Several times
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LSI
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Likely
22 (11.5)
39 (13.6)
26 (13.6)
47 (16.4)
10.707 [3]
.013
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Note. Eight missing in gender, one missing in LSI (in female students), and two missing in SA (both in male students). SBQ-R = Suicide Behaviour Questionnaire – Revised. SA= Suicide acceptability.
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LSI= Lifetime suicidal ideation.
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Table 2. Spearman’s Correlation Between SBQ-R and SA and LSI SA
LSI
Mean (SD)
(N=485)
(N=484)
SBQ-R1
1.69 (1.10)
.56**
.34**
SBQ-R2
1.56 (.77)
.60**
SBQ-R3
1.39 (.67)
.46**
SBQ-R4
1.16 (1.60)
.64**
Total score
5.79 (3.54)
.68**
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Variables
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.33** .27** .28** .32**
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Note. ** p <.0001. SBQ-R = Suicide Behaviour Questionnaire – Revised. SA= Suicide
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two data for LSI were missing.
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acceptability. LSI= Lifetime suicidal ideation. SD = Standard deviation. One datum for SA and
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Table 3. Applicability of SBQ-R’s Cut-off Points Using Logistic Regression by FSA and LSI (N = 484) SBQ-R ≥ 7a
SBQ-R ≥ 8b
OR
95% CI
OR
95% CI
FSA
12.18
[6.96, 21.31]
11.85
[6.77, 20.74]
Reference
Once
8.25
[3.70 ,18.41]
A couple of times
17.29
Several times
1.48
[2.52, 12.39]
[7.95 ,37.62]
16.27
[7.65, 34.60]
2.24
[1.07, 4.66]
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5.58
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Never
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LSI
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Independent variables
[.73, 3.0]
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Note. Three data were missing (Listwise deletion). LSI = Lifetime suicidal ideation. FSA= Favored to suicide acceptability. OR= Odds ratio. CI= Confidence Interval. Constant was
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included in regressions. SA was transformed into a dichotomous variable of low (scores 1 to 3) and high (scores 4 & 5) suicide acceptability. a.Hosmer and Lemeshow Test: Chi-square = 2.852, df =3, p=.415. -2 Log likelihood = 374.623, Cox & Snell R Square = .37, Nagelkerke R Square= .52.
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b. Hosmer and Lemeshow Test: Chi-square = 1.857, df =3, p=.603. -2 Log likelihood = 341.885, Cox & Snell R Square = .35, Nagelkerke R Square= .51.
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PII:
S1876-2018(19)30728-2
DOI:
https://doi.org/10.1016/j.ajp.2019.101856
Reference:
AJP 101856
To appear in:
Asian Journal of Psychiatry
Received Date:
8 August 2019
Revised Date:
27 September 2019
Accepted Date:
21 October 2019
Please cite this article as: Amini-Tehrani M, Nasiri M, Jalali T, Sadeghi R, Ghotbi A, Zamanian H, Validation and Psychometric Properties of Suicide Behaviors Questionnaire-Revised (SBQ-R) in Iran, Asian Journal of Psychiatry (2019), doi: https://doi.org/10.1016/j.ajp.2019.101856
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.
Validation and Psychometric Properties of Suicide Behaviors Questionnaire-Revised (SBQR) in Iran
Mohammadali Amini-Tehrania,b, Mohammad Nasiria, Tina Jalalib, Raheleh Sadeghib, Amene Ghotbib, Hadi Zamanianc,b*
Department of Psychology and Education, University of Tehran, Tehran, Iran
b
Health Psychology & Behavior Medicine Research Group, Students Scientific Research Center,
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a
Tehran University of Medical Sciences, Tehran, Iran. Qom University of Medical Sciences, Qom, Iran.
*
Corresponding Author: Hadi Zamanian, MD, PhD in Health Education and Promotion, School
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c
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of Health, Qom University of Medical Sciences, Lavasani St., Qom, Iran. Tel: +983713649373, Fax: +9837706470, Postal Code: 3713649373, Email: [email protected],
Highlights
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[email protected], Mobile: +989123543893
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Research on suicide in Iran lacks comprehensive assessment tools, beyond Ideations Suicide Behavior Questionnaire-Revised shows sound reliability and validity The suicide-related behaviors and risk of Iranian undergraduates were notable Female students had a higher score in terms of different suicide-related behaviors
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Abstract Background: Suicide is increasing in young Iranian population, which necessitates the
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employing of valid, yet abridged instruments assessing the constellation of suicide-related
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behaviors. The study aimed at validating Suicide Behavior Questionnaire-Revised (SBQ-R) among Iranian undergraduates.
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Methods: A total of 487 undergraduates were surveyed in 2018. Construct validity of SBQ-R
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was examined via confirmatory factor analysis (CFA), and Spearman’s correlation with two single-item indices of suicide acceptability (SA) and lifetime suicidal ideation (LSI) was determined. Logistic regression and Kruskal-Wallis tests were used to examine the cut-off points
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(≥ 7 and ≥ 8) and categorizations as per item 1.
Results: The mean SBQ-R score was 5.79±3.55. Cut-off points ≥ 7 and ≥ 8 categorized 150 (30.8%) and 123 (25.2%) samples with suicide risk, respectively. Women obtained significantly
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higher scores on all indices, except items 1 and 4. CFA confirmed the model with sound goodness-of-fit, with factor loadings of 0.70 to 0.83. Composite reliability and average variance extracted were 0.87 and 0.63, respectively. The SBQ-R’s correlation with SA and LSI confirmed its concurrent validity. Regression analysis confirmed the ability of both cut-off points to distinguish the participants with high SA and LSI; however, the cut-off point ≥ 8 produced better
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results regarding high LSI. Based on item 1, normal versus low- and high-risk samples were significantly different in terms of SA, LSI, and adjusted total score of SBQ-R (P< 0.0001). Conclusion: SBQ-R is an economic and psychometrically sound tool, which can be utilized to identify suicide-related behaviors and risks in young Iranian population. Keywords: Assessment; Confirmatory Factor Analysis; Suicide; SBQ-R; Validation
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Introduction Suicide and its associated factors are critical global issues, affecting different domains of life,
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regardless of culture, nation, religion, gender, or social class. Approximately one million people die by suicide every year worldwide, with China and India accounting for almost 50% of the
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overall suicide rate (Mann, 2002). Although under-reporting of suicidal ideation and behavior is
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highly likely in the Iranian population, the prevalence of suicidal thoughts, plans, and attempts has been estimated at 12.7%, 6.2%, and 3.3%, with incidence rates of 5.7%, 2.9%, and 1%,
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respectively (Malakouti et al., 2009). According to some studies, young Iranian people, aged 1524 and 25-34 years, constitute a large proportion of suicide attempters, with 48% and 32.5%,
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respectively (Mirahmadizadeh et al., 2019). Also, the growing rate of suicidal attempts and deaths during the past decades indicate the increased risk of suicidality in Iran (HassanianMoghaddam & Zamani, 2017; Mirahmadizadeh et al., 2019). Suicide-related behaviors have been also reported as a major issue among university students (Katsumata et al., 2017; Mortier et
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al., 2018).
Silverman et al. (2007a) developed a uniform terminology for suicide-related behaviors,
including suicidal ideations, communications (suicide threats and plans), attempts, and suicide, which require the intention to die. Therefore, to determine the suicide risk in a given population, appropriate scales are expected to incorporate different dimensions of suicide-related behaviors. 3
The Suicide Behaviors Questionnaire-Revised (SBQ-R) has been used in many studies to evaluate suicidal thoughts, plans, communication, attempts, and risks, which address the individual’s deadly intent (Osman et al., 2001). Osman et al. (2001) designed SBQ-R based on an original work of Linehan and Nielsen (1981). This shortened scale contains four items on suicidal behaviors and ideations over the past
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12 months, suicide-related communication, and self-reported likelihood of any future suicidal behavior. The total score of SBQ-R ranges from 3 to 18, with higher scores indicating a higher
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risk of suicide (Osman et al., 2001). Osman et al. (2001) validated this instrument in four groups of adolescent psychiatric inpatients, high school students, adult psychiatric inpatients, and
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undergraduates. They found that scores ≥ 7, with a sensitivity of 0.93 and specificity of 0.95,
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could indicate the risk of suicide in the general adult population (Osman et al., 2001). SBQ-R has been approved as a useful scale for suicide risk assessment in clinical and non-clinical samples
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(Ghasemi et al., 2015). It has also been employed in different populations (Aloba et al., 2017; Glaesmer et al., 2018; Lund et al., 2017).
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Although this instrument was translated in an unpublished study by Safa and Boroujerdi (Safa et al., 2014) and applied in an Iranian population (Shakeri et al., 2015), there is no report of its validity or reliability. Suicide research in Iran has been focused on suicide attempts (Mokhtari et al., 2019), while there is a crucial need for more investigation on different psychological,
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interpersonal, social, and cultural contributing factors to the issue. Besides, employing valid and reliable, yet short instrument is fundamental to behavioral research. Therefore, in the present study, we aimed to evaluate the construct validity, concurrent validity, internal consistency, and applicability of SBQ-R in Iranian students.
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Methods Design and sampling The present study was conducted during April-May 2018 as part of “Suicidality-RP Factors Project.” An institutional board reviewed the study protocol and the Iranian National Committee for Ethics in Biomedical Research approved the study. The sample was university
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undergraduates, within the age range of 18-29 years. Informed consent was obtained. Sampling was carried out in an Iranian university among students from three educational fields of
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humanities (five schools), engineering (one school), and basic sciences (two schools). A total of 524 booklets were distributed in classrooms in sealed envelopes to ensure confidentiality during
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data collection. However, 33 booklets were incomplete, one participant graduated from the
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university during the study, and three participants were unwilling to answer suicide-related questions. Finally, 487 booklets were studied in the final analysis (response rate: 92.9%).
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The age range of the participants was 19-28 years (20.66±1.42). The majority of the participants were female (n=288, 59.2%). Also, the majority were studying humanities (n=254,
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52.2%), followed by engineering (n=124, 25.5%) and basic sciences (n=109, 22.4%). In terms of ethnicity, most of the participants were Fars (n=262, 53.8%), followed by Turk (n=113, 23.2%), Mazani/Gilak (n=40, 8.2%), Lor (n=21, 4.3%), Kurd (n=14, 2.9%), and other ethnicities including Baluch, Arab, and Turkman (n=15, 2.1%). The samples mostly lived with their
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families (n=326, 66.9%) or in university dormitories (30.2%, n=147). Also, most of them were single (n=466, 95.7%). Concurrent validity measurements Suicide acceptability (SA) was measured as a single-item index. The participants completed the following statement: “Some argue that suicide is the right choice for an individual, as a remedy 5
from pain, misery, and suffering. In your opinion, suicide is…” The participants completed the statement on a five-point Likert scale (“completely unacceptable,” “mostly unacceptable,” “no opinion,” “mostly acceptable,” and “completely acceptable”). Some previous studies have reported that a permissive attitude towards suicide can be a risk factor for suicidal ideation (Kodaka et al., 2013). Therefore, we hypothesized that SA has a positive relationship with the
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scale items and total score (H1). We also hypothesized that students, who agreed with suicide as an acceptable option, would be exposed to a higher risk of suicide, as measured by SBQ-R (H2).
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Besides, lifetime suicidal ideation (LSI) was measured as a single-item index. The
participants answered the following question: “Have you ever seriously thought about taking
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your own life?” The responses included: “never” (score 0), “once” (score 1), “a couple of times”
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(score 2), and “several times” (score 3). We hypothesized that LSI has a positive relationship with the scale items and total score (H3). We also hypothesized that a higher LSI would increase
Data analysis
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the risk of suicide (H4).
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Descriptive statistics were measured to report the frequency of suicide-related behaviors and the mean score of the study sample. Construct validity was examined using confirmatory factor analysis (CFA) with robust maximum likelihood (MLR) in Mplus software (Muthen & Muthen, 1998-2012). MLR is considered suitable for data without a normal distribution, yielding
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maximum likelihood estimations with robust standard errors (Suh, 2015). We used composite reliability (CR> 0.70) as an index of internal consistency and the average variance extracted (AVE> 0.50) as an index of variance explained by the measurement model to evaluate the validity of the latent construct (Hair et al., 2010). Moreover, Cronbach’s alpha coefficient (>
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0.70) was measured, and Spearman’s correlation coefficient (rho) was determined for the correlational analysis of SA and LSI with SBQ-R items and total SBQ-R score. Two further steps were incorporated to examine the applicability of SBQ-R. First, univariate logistic regression was used to investigate how SBQ-R cut-off points ≥ 7 and ≥ 8, as indicators of suicide risk, would be applicable relative to SA and LSI. The dummy variable of
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suicide risk (1= total score ≥ 7, 0 = total score < 7) was entered in the model as the dependent variable. LSI was also included as an independent categorical variable with reference to the
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lowest category (i.e., “never”). On the other hand, SA was transformed into a dichotomous
variable with low (score: 1-3) and high (score: 4-5) acceptability; score 1 indicated the person’s
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favoring of SA (FSA).
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Both LSI and FSA were simultaneously entered in the model as independent variables. Second, SBQ-R item 1 was used for categorization of normal (“never” and “a brief passing
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thought”), low suicide risk (“plan” with and without intention to die), and high suicide risk (“attempt” with and without intention to die) groups. We hypothesized that there would be a
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significant difference between the groups in terms of the adjusted total score of SBQ-R (sum of SBQ-R items 2-4), SA, and LSI (H5).
Kruskal-Wallis test was used for multiple group comparisons. Data analysis was carried out in SPSS V. 24 (IBM Inc., USA) and Mplus V. 7.4 (15). P-value < 0.05 (95% CI) was considered
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statistically significant. Results
Suicide-related behaviors The mean (standard deviation) scores of SBQ-R items were 1.69±1.10, 1.56±.77, 1.39±.67, and 1.16±1.60, respectively, with a total score of 5.79±3.55 (range: 3-18). The mean score of SA was 7
2.24±1.30, and the mean score of LSI was 1.81±1.15. Table 1 presents the detailed pattern of responses to SBQ-R items, SA, and LSI. As shown in Table 1, there was a significant difference between male and female students in terms of SBQ-R2, SBQ-R3, suicide risk, SA, and LSI; in other words, female students obtained higher scores than their male counterparts. These rates were discussed in another publication on this dataset (ANONYMOUS), and they are reported
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here as sample description. Construct validity and reliability
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CFA indicated that the model fit the data well (Chi-square= 0.682; DF= 2; P= 0.711; GFI=
0.999; CFI= 1.0; TLI= 1.0; RMSEA= 0.00; 90% CI= [0.0, 0.065]; PCLOSE= 0.897). Factor
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loadings (standard error) for items 1 to 4 were 0.831 (0.026), 0.827 (0.025), 0.697 (0.038), and
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0.799 (0.028), respectively (P< 0.00001). CR (0.869), AVE (0.625; 63% of total variance), and Cronbach’s alpha (0.82) confirmed the internal consistency and variance explained by the latent
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construct. Convergent and divergent validity
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According to Spearman’s correlation coefficients presented in Table 2, SA and LSI had significant positive relationships with SBQ-R items and the total score (P< 0.0001). The results confirmed hypotheses H1 and H3, indicating the concurrent validity of SBQ-R. Applicability of SBQ-R
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Table 3 presents the results of logistic regression analysis. Regarding the cut-off point ≥ 7, our results indicated that the suicide risk increased significantly by FSA (12.18; 95% CI= [6.96, 21.13]). Also, with “no LSI” as the reference category, categories of “once” (8.25; 95% CI= [3.70, 18.41]) and “a couple of times” (17.29, 95% CI= [7.95, 37.62]) were associated with a significant increase in suicide risk. On the other hand, despite the increased risk of suicide (1.48) 8
associated with the category of “several times,” no significant difference was observed (95% CI= [0.73, 3.0]). These results were also true for the cut-off point ≥ 8. This cut-off point could also differentiate samples, who selected the category of “several times” (OR= 2.24; 95% CI= [1.07, 4.66]). Therefore, our hypotheses (H2 and H4) regarding the applicability of SBQ-R cut-off points in Iranian students were confirmed.
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Regarding item 1, the results of Kruskal-Wallis test showed significant differences between the three subgroups of normal, low suicide risk, and high suicide risk in terms of the
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adjusted SBQ-R score (df= 2; test statistics= 198.547; asymptotic P< 0.0001), SA (df= 2; test statistics= 95.481; asymptotic P< 0.0001), and LSI (df= 2, statistics= 70.530, asymptotic P<
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0.0001). Also, pair-wise comparisons indicated significant differences between the normal and
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low-risk groups (adjusted P< 0.0001), as well as the normal and high-risk groups (adjusted P< 0.0001) in terms of all three indices; however, the difference was insignificant between the low-
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and high-risk groups (adjusted P= 0.496 for adjusted total score; adjusted P= 0.237 for SA; and adjusted P= 0.815 for LSI); therefore, hypothesis H5 was also confirmed.
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Discussion
Although many researchers have continuously reported suicide-related issues in Iranian populations, especially young people, no comprehensive, yet economic scale has been introduced to assess the broad range of suicidal behaviors. SBQ-R presents a short, suitable instrument,
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which can be incorporated into research on suicidality in different populations. Although the scale was previously translated by Safa and Boroujerdi (Safa et al., 2014), there is no detailed information about its validity and psychometric properties. Therefore, in the current study, we aimed to examine the validity, reliability, and applicability of SBQ-R in an Iranian sample of undergraduates. 9
CFA confirmed the unidimensionality of SBQ-R. The results indicated quite sound goodness-of-fit of the model, along with strong factor loadings, which explained a valid proportion of variance in the latent construct (Hair et al., 2010). Some recent studies have also confirmed the construct validity and unidimensionality of SBQ-R, based on CFA (Campos & Holden, 2019; Glaesmer et al., 2018). Also, the current study indicated the concurrent validity of
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this scale, considering its significant positive relationship with lifetime suicide ideation (LSI) and, in particular, suicide acceptability (SA) (Kodaka et al., 2013). Generally, assessment of
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suicide risk requires the evaluation of a constellation of suicide-related behaviors, including
suicidal ideations, communications, plans, and attempts, which are suggested as constitutive
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aspects of suicide risk (Silverman et al., 2007a, 2007b). According to these findings, SBQ-R, as
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a short scale of essential suicide-related behaviors, can be used to assess the valid construct of suicide risk.
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Internal consistency of SBQ-R was also acceptable, with composite reliability of 0.86 for the latent construct in CFA (Hair et al., 2010) and Cronbach’s alpha of 0.82. In this regard, a
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study by Osman et al. (Osman et al., 2001) reported a Cronbach’s alpha coefficient of 0.88. Furthermore, validation studies have reported a Cronbach’s alpha of 0.77 for people with and without disability (Lund et al., 2017), 0.72 for German adults (Glaesmer et al., 2018), and 0.69 for Portuguese undergraduates (Campos & Holden, 2019). Since internal consistency is a unique
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feature of each study sample (Tavakol & Dennick, 2011), these consistent results indicate the inter-relatedness of the four items of the scale in various populations. Our investigation of the applicability of cut-off points (≥ 7 and ≥ 8), as suggested by
Osman et al. (2001), revealed that both cut-off points could significantly predict SA and LSI. However, the cut-off point ≥ 8 showed higher accuracy in differentiating the category of “high 10
LSI.” Some recent studies have confirmed the validity of the cut-off point ≥ 7 in distinguishing suicide attempters from non-attempters, with a sensitivity of 0.89 and specificity of 0.82 (Campos & Holden, 2019). Also, the first item of the scale could differentiate between normal (score 1) and clinical (scores 2 and 3) groups in terms of SA, LSI, and adjusted total score of SBQ-R.
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In line with the results of the original study by Osman et al. (2001), we found that SBQ-R could reliably address suicide risk in young populations, particularly undergraduates. Some
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scholars argue that suicide risk assessment is far beyond a simple analysis using structured or semi-structured tools, given the importance of suicidal intentions and the ultimate goal of health
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professionals, which is to reduce the risk of suicide (Simon, 2012). According to Murray
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(Murray, 2016), since suicide risk assessment (i.e., prediction) aims at identifying individuals at risk of actual death, the high rate of false-negative and false-positive diagnoses, represented by
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suicide categorizations (e.g., high suicide risk), may prevent adequate care and support for these patients.
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Conversely, some experimental studies suggest that suicide, at least at cognitive levels (i.e., thoughts and ideations), can indicate a low desire for life rather than a desire for death (Harrison et al., 2014). This notion is consistent with the results of some recent studies, which have revealed the importance of one’s meaning-focused coping strategies in the face of adverse
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life events (Wang et al., 2019). Moreover, the suicidal tendencies of a university student can affect his/her peers (Ash, 2012) and increase the risk of low academic performance in the early years of university (Mortier et al., 2015). Insofar as the suicidal tendency is an important indicator of an undesirable life, reduced well-being, and low performance, future research may benefit from suicide assessment tools to identify individuals at risk of suicide. 11
This study was performed on a student population, selected from one single university; therefore, the results cannot be generalized to all populations of Iran. Future studies can include a validation analysis of SBQ-R in psychiatric inpatient populations to investigate its performance in terms of criterion validity, test-retest reliability, and cut-off points in Iranian people. Also, the use of single-item measures for the evaluation of concurrent validity can be argued, especially
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concerning the validity and accuracy of construct measurements. Nevertheless, our findings are consistent with the available information in the field, which suggests SBQ-R applicability in
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different populations. Conclusion
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SBQ-R is an economic and psychometrically sound instrument, which can be incorporated into
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public health, health psychology, and clinical psychology studies to identify suicide-related behaviors in different populations. Also, this abbreviated scale can be useful in experimental
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research on the development, expansion, and re-evaluation of suicide theories (Gunn & Lester,
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2015), which seems essential in Iran.
Authors Contributions
MAT contributed to conceptual design, statistical analysis, data gathering, and finalizing the
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manuscript. MN, TJ, and RS contributed to data collection. AG contributed to statistical analysis and provision of the original draft. HZ contributed as the supervisor in conceptual design and as the corresponding author.
Conflict of Interest 12
Authors declare that there is no conflict of interest regarding any aspects of the publication of this article.
Financial Disclosure MAT as the master student of University of Tehran, Iran, received partial grant for conducting
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the project.
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Conflict of Interest
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Authors declare that there is no conflict of interest regarding any aspects of the publication of this article.
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Figure 1. Confirmatory factor analysis of SBQ-R with MLR estimator, modelled by Mplus (Muthen & Muthen, 2012). The factor loadings (standard error) are standardized estimations (p <.00001). Chi-square = 0.682, DF = 2, p= .711, GFI = .999, CFI = 1.0, TLI=1.0, RMSEA = .00,
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90%CI= [.0, .065], PCLOSE= .897. Composite reliability (CR) = .869. Average variance extracted (AVE) = .625.
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Table 1. Frequency of Suicide-related Behaviors ( N = 487) Female Students (n = 288)
n (%)
SBQ-R1 Never
287 (58.9)
123 (64.4)
162 (56.3)
A brief Passing thought
141 (29.0)
54 (28.3)
83 (28.8)
A plan without trying
33 (6.8)
6 (3.1)
25 (8.7)
A plan with intention to die
14 (2.9)
4 (2.1)
10 (3.5)
Attempt with no intention to die
4 (0.8)
3 (1.6)
1 (0.3)
Attempt with intention to die
8 (1.6)
1 (0.5)
SBQ-R2 Never
306 (62.8)
Rarely
97 (19.9)
Sometimes
37 (7.6)
re 38 (19.9)
40 (13.9)
11 (5.8)
22 (7.6)
25 (5.1)
4 (2.1)
23 (8.0)
22 (4.5)
12 (6.3)
11 (3.8)
347 (71.3)
149 (78.0)
178 (61.8)
One time, no intention to die
64 (13.1)
23 (12.0)
56 (19.4)
One time , with intention to die
26 (5.3)
4 (2.1)
25 (8.7)
More than once, no intention to die
35 (7.2)
12 (6.3)
19 (6.6)
3 (1.6)
10 (3.5)
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192 (66.7)
SBQ-R3 No
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Very Often
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More than once , with intention to 15 (3.1) die SBQ-R4 Never
270 (55.4)
111 (58.1)
157 (54.5)
No chance at all
59 (12.1)
25 (13.1)
33 (11.5)
Rather Unlikely
63 (12.9)
27 (14.1)
33 (11.5)
Unlikely
31 (6.4)
10 (5.2)
20 (6.9)
19
.076
12.043 [5]
.034
11.321 [4]
.023
8.343 [6]
.214
7 (2.4)
126 (66.0)
Often
pvalue
8.454 [4]
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Variables
Chi-square [df]
of
Male Students (n = 191)
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Total sample (N = 487)
44 (9.0)
11 (5.8)
33 (11.5)
Rather Likely
11 (2.3)
2 (1.0)
8 (2.8)
Very Likely
9 (1.8)
5 (2.6)
4 (1.4)
Suicide risk ≥7
150 (30.8)
48 (25.1)
98 (34.0)
4.29 [1]
.038
≥8
123 (25.3)
35 (18.3)
84 (29.2)
7.230 [1]
.007
SA Completely unacceptable
215 (44.3)
101 (53.4)
112 (38.9)
Mainly unacceptable
76 (15.7)
28 (14.8)
47 (16.3)
No opinion
72 (14.8)
25 (13.2)
45 (15.6)
Mainly acceptable
109 (22.5)
30 (15.9)
76 (26.4)
Completely acceptable
13 (2.7)
5 (2.6)
8 (2.8)
302 (69.0)
134 (70.2)
166 (57.8)
47 (9.7)
9 (4.7)
35 (12.2)
63 (13) 74 (15.2)
.02
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11.707 [4]
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Never Once A couple of times Several times
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LSI
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Likely
22 (11.5)
39 (13.6)
26 (13.6)
47 (16.4)
10.707 [3]
.013
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Note. Eight missing in gender, one missing in LSI (in female students), and two missing in SA (both in male students). SBQ-R = Suicide Behaviour Questionnaire – Revised. SA= Suicide acceptability.
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LSI= Lifetime suicidal ideation.
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Table 2. Spearman’s Correlation Between SBQ-R and SA and LSI SA
LSI
Mean (SD)
(N=485)
(N=484)
SBQ-R1
1.69 (1.10)
.56**
.34**
SBQ-R2
1.56 (.77)
.60**
SBQ-R3
1.39 (.67)
.46**
SBQ-R4
1.16 (1.60)
.64**
Total score
5.79 (3.54)
.68**
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Variables
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.33** .27** .28** .32**
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Note. ** p <.0001. SBQ-R = Suicide Behaviour Questionnaire – Revised. SA= Suicide
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two data for LSI were missing.
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acceptability. LSI= Lifetime suicidal ideation. SD = Standard deviation. One datum for SA and
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Table 3. Applicability of SBQ-R’s Cut-off Points Using Logistic Regression by FSA and LSI (N = 484) SBQ-R ≥ 7a
SBQ-R ≥ 8b
OR
95% CI
OR
95% CI
FSA
12.18
[6.96, 21.31]
11.85
[6.77, 20.74]
Reference
Once
8.25
[3.70 ,18.41]
A couple of times
17.29
Several times
1.48
[2.52, 12.39]
[7.95 ,37.62]
16.27
[7.65, 34.60]
2.24
[1.07, 4.66]
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5.58
re
Never
ro
LSI
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Independent variables
[.73, 3.0]
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Note. Three data were missing (Listwise deletion). LSI = Lifetime suicidal ideation. FSA= Favored to suicide acceptability. OR= Odds ratio. CI= Confidence Interval. Constant was
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included in regressions. SA was transformed into a dichotomous variable of low (scores 1 to 3) and high (scores 4 & 5) suicide acceptability. a.Hosmer and Lemeshow Test: Chi-square = 2.852, df =3, p=.415. -2 Log likelihood = 374.623, Cox & Snell R Square = .37, Nagelkerke R Square= .52.
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b. Hosmer and Lemeshow Test: Chi-square = 1.857, df =3, p=.603. -2 Log likelihood = 341.885, Cox & Snell R Square = .35, Nagelkerke R Square= .51.
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