Development and validation of the Redeemer’s University Suicidality Scale

[Find the meaning and references behind the names: Daniel, Mar, Smart, Ebenezer, Good]

http://www.sajpsychiatry.org Open Access South African Journal of Psychiatry ISSN: (Online) 2078-6786, (Print) 1608-9685 Page 1 of 9 Original Research Read online: Scan this QR code with your smart phone or mobile device to read online Authors: Bede C. Akpunne 1 Ebenezer O. Akinnawo 2 Abayomi O. Olusa 1 Daniel O. Kumuyi 1 Affiliations: 1 Department of Behavioural Studies, Faculty of Social Science, Redeemer’s University, Ede, Nigeria 2 Department of Pure and Applied Psychology, Faculty of Social Sciences, Adekunle Ajasin University, Akungba, Nigeria Corresponding author: Bede Akpunne, akpunneb@run.edu.ng Dates: Received: 01 Sept. 2021 Accepted: 25 Sept. 2022 Published: 29 Mar. 2023 How to cite this article: Akpunne BC, Akinnawo EO, Olusa AO, Kumuyi DO. Development and validation of the Redeemer’s University Suicidality Scale. S Afr J Psychiat. 2023;29(0), a 1799. https://doi.org/10.4102/ sajpsychiatry.v 29 i 0.1799 Copyright: © 2023. The Authors. Licensee: AOSIS. This work is licensed under the Creative Commons Attribution License Introduction Suicide was the 18 th most prominent cause of death worldwide, accounting for 1.4 % of deaths. 1 Suicide is also one of the top 10 causes of death in the general population and the second-highest cause of mortality among people aged 15–34 years old. 2,3,4,5 Suicide affects people of all ages. Suicide is the second leading cause of death for those aged 10–34, the fourth leading cause of death for people aged 35–54 and the eighth leading cause of death for people aged 55–64 in the United States of America. 2 Every year, over 800 000 people die by suicide around the world, and it is estimated that for every person who dies by suicide, more than 20 others attempt suicide. 3,6 According to statistics, the rate of suicide varies by country and location. 4 Although suicidal behaviour and non-suicidal self-harm are related terms, the two concepts are different. While suicide is an act of escaping pain and suffering by taking one’s own life, selfinjury is a non-suicidal activity used as a coping mechanism. It can provide relief from excruciating pain or emotional numbness and can last for weeks, months or even years. 7 Non-suicidal selfharm is a behaviour that people engage in when trying to cope with negative feelings or pain. Cutting, burning, scratching, head-banging and punching walls are examples of non-suicidal selfharm. Non-suicidal self-harm involves deliberate activities designed to alleviate emotional discomfort or bad feelings. Suicidal behaviour, on the other hand, entails contemplating, planning, imagining or acting on suicidal ideas or urges. It refers to any action taken by a person to end their life. 8 Some of the differences are the motivation behind actions, the quantity of damage, the method of self-harm, the frequency of action and so on. 8 Background: The need for a culturally suitable scale for suicidality within the multilingual Nigerian society necessitated this research interest Aim: The study is a development and validation of the Redeemer’s University Suicidality Scale (RUSS) Setting: South western Nigeria Methods: This comprised of initial generation of items; face and content validity, item refinement and administration of RUSS to 150 university undergraduates, using exploratory factor analysis at the first, second and third stages. In the fourth stage, 184 undergraduates responded to the 20-item RUSS, Suicide Ideation Scale (SIS) and General Health Questionnaire (GHQ-12). Data gathered at this stage were analysed for congruent validity, reliability and norms. Results: The principal component analysis extracted four components from items whose eigenvalues exceeded one. Twenty-one of the 25 items loaded best in the first, two in the second and one on the third component(s). Only items in the first component were retained. Item-total correlation further showed that the values of one item in the first component fell below the very good discrimination and was deleted from the scale. The RUSS has a Cronbach’s alpha of 0.93. Congruence validity coefficient of r = 0.881 ( p < 0.001) and r = 0.605 ( p < 0.001) was observed between RUSS and SIS and between RUSS and GHQ-12, respectively Conclusion: The RUSS is gender-sensitive, has acceptable psychometric properties and is recommended as a diagnostic tool for assessing suicidal behaviour in adolescents and adults. Contribution: This article contributes to the development of a culture sensitive measure for suicidality Keywords: development; validation; culturally suitable; suicidality scale; Nigeria Development and validation of the Redeemer’s University Suicidality Scale Read online: Scan this QR code with your smart phone or mobile device to read online.

[Find the meaning and references behind the names: Long]

Page 2 of 9 Original Research http://www.sajpsychiatry.org Open Access Suicidal behaviour encompasses a variety of behaviours that have the same goal of killing oneself. Suicidal behaviour, however, differs from non-suicidal self-injury, which is a deliberate destruction of one’s own bodily tissue with no lethal intent, although the two behaviours might lead to dying Suicidal ideation, planning and attempts are three essential suicidal behaviours. Suicidal ideation occurs when a person considers or plans to commit suicide. 3 Suicidal ideation encompasses a wide spectrum of behaviours, from fleeting thoughts to long-term plans. Suicidal ideations, often known as suicidal thoughts or ideas, is a broad term that refers to a variety of thoughts, aspirations and preoccupations with death as well as the inclination or desire to terminate one’s own life 9,10 Suicidal ideation can range from passive (wanting to die) to active (wanting to kill oneself or thinking of a specific method for doing it) A suicide plan is defined as ‘a proposed technique of carrying out a design that may result in self-injury; a systematic development of a plan of action that may result in selfinjury’ 11 Finally, attempting suicide is a planned act of ending one’s life. It is a self-inflicted, possibly harmful behaviour with a nonfatal outcome for which there is evidence of a desire to die (either explicit or implicit). 11 Overdosing or ingesting is the most common means of suicide attempt among teenagers, followed by hanging or suffocation and using a sharp object (e.g. cutting) 12,13 Different theories have been used to explain suicidal behaviour. One of them is the ideation-to-action framework proposed by Klonsky and May. 14 According to this model, the development of suicidal ideation and the progression from suicidal ideation to attempts should be seen as distinct processes having distinct predictors and explanations. The ideation-to-action framework sheds more light on what the traditional approaches (psychache, social isolation, escape from aversive selfcognitions, hopelessness and so on) could not explain (i.e. offering different explanations for the development of suicidal ideation and the progression from ideation to attempt). The traditional differs from the ideation-to-action model in that the former treats suicide as a risk and a unitary construct. At the same time, the latter distinguishes ideation predictors from the progression from ideation to behaviour The ideation-to-action framework, which specifies: (1) the development of suicidal ideation and (2) the transition from ideation to suicide attempts, is one perspective in the study of suicide. Suicidal ideation, suicide attempts and suicide are all included in this framework, 15 with suicidal ideation being the first phase of suicide. As a result, any self-initiated or committed activities with the aim or expectation of dying, including active or passive self-inflicted acts, are considered suicide 16 Another significant advancement is a growing collection of research distinguishing between characteristics that predict suicide thoughts and those that predict attempted suicide. 17 According to studies, most suicidal behaviours occur when people are thinking about it. 18 Suicidal behaviour is influenced by various biological, psychological, social, cultural and spiritual variables Suicidal ideation is defined as a desire or consideration of suicide 19 In the literature, there are two types of suicidal ideation (passive and active). Passive suicidal ideation happens when someone aspires to die or believes they might die but has no intention of actually doing so. Active suicidal ideation, on the other hand, refers to the act of thinking about, intending to and planning to commit suicide 19 Suicidal ideation is a significant risk factor for suicide in adolescents and young people. 20,21 Suicidal ideation has been reported by almost a third of teenagers aged 12–20 years in the United Kingdom 22 Suicidal behaviour is common among those suffering from mental illnesses such as depression, schizophrenia, bipolar disorder and substance misuse 19 However, it is not always associated with an underlying disease or a genuine desire to die 23 Despite the global rise in suicide rates, Rukundo et al. 24 found a data vacuum in suicidal behaviour among children and adolescents in poor and middle-income African nations Like many other countries, Nigerian research shows an alarming rate of suicide deaths 25,26 For instance, according to 2019 statistics, there is a 3.5 suicide rate per 100 000 Nigerians 27 Based on an estimated 2021 population of over 211 million people, the death by suicide figure in 2021 was about 7400 27 Most suicide deaths occur in underdeveloped nations such as Nigeria 17 and are often undetected 28 and grossly unreported. 6,29,30 According to the World Health Organization’s (WHO) 2018 rating, 3 Nigeria has the highest suicide rate in Africa and ranks fifth in the world in terms of acute suicide cases, trailing only South Korea, Russia, India and Japan. 31 Justification for the study The rate of death by suicide is high in Nigeria 3,25,26,32 Nigeria, with a population of over 200 million people, has a high suicide prevalence rate 1 Judging from the identified perpetuating risk factors such as poverty, financial constraints, issues with relationships, loss of loved ones, family history of suicide, mental illness, substance abuse and physical illness, 32 and the dearth of data on suicide resulting from under-reporting for fear of stigmatisation, 33 there is a need for a standardised scale to identify suicidal behaviour among Nigerians This scale will help in early risk identification, reducing suicide deaths if adequate interventions are provided and practical policy declarations to address it. The need for an indigenous scale that considers the unique sociocultural elements that affect Nigerians and how these factors influence suicidal behaviour form a strong argument for this study. Based on this background, the authors set out to create and validate an indigenous suicidality scale.

[Find the meaning and references behind the names: Law, Glenn, Brown]

Page 3 of 9 Original Research http://www.sajpsychiatry.org Open Access Research methods and design Study sample The sample size calculation was based on the table of sample size determination published by Glenn 34 For a sample size for ± 10 % precision levels where confidence level is 95 % , and p = 0.5 for 4000, a population sample size of 98 was calculated. 34 Based on a previous pilot study conducted using 180 participants, there was a 35.9 % prevalence of suicidal behaviour. To account for attrition, a sample size of 150 and 184 participants who consented was used for the exploratory factor analysis (EFA) and the determination of the psychometric properties of the Redeemer’s University Suicidality Scale (RUSS), respectively The participants’ ages ranged between 15 and 34 years (mean = 19.72; s.d = 3.61). A cross-sectional method was used to select participants from all levels of study in the seven faculties in the selected institution. The faculties are Natural Sciences, Social Sciences, Management Sciences, Humanities, Law, Basic Medical Sciences and Engineering For the inclusion and exclusion criteria, only registered students who were university undergraduates and currently on full-time study bases, found within the selected university campus, were selected for the study. This inclusion was meant to provide valid research outcomes by controlling for possible error in the responses caused by students who were not undergraduate students or students who were not on a full-time study basis but might be around the university campuses at the time of instrument administration. Also, only students willing to answer and return the questionnaires to the researcher were included in the study. This inclusion criterion enabled the researcher to ensure that all the prospective participants were well enlightened and understood the purpose of the study; as such, motivation and true responses were guaranteed. Studies at the international 35 and Nigerian levels 36, 37 show that the age category 18–29 years is reported to have the highest prevalence of suicidal behaviour. Also, suicide is more prevalent among undergraduates, 32 hence choosing this population for the study. Previous studies have suggested being young as a risk factor for suicidal behaviour. 38 Study setting This study was carried out among undergraduate students at a private university in south-western Nigeria Study instruments The participants responded to the RUSS, the Suicide Ideation Scale (SIS) 39 and the General Health Questionnaire 12 (GHQ-12) 40 The SIS, originally developed for and validated with nonclinical samples of young adults, was designed as a brief measure of ideation for use among clinical and nonclinical populations. The SIS is a 10-item self-report scale designed to assess the severity or intensity of suicide ideation. Responses on the SIS are scored on a Likert-type scale with anchors at 1 (never or none of the time) to 5 (always or a great many times) based on how the respondent has felt or behaved over the past year. Items in the SIS are: • I have been thinking of ways to kill myself. • I have told someone I want to kill myself. • I believe my life will end in suicide. • I have made attempts to kill myself. • I feel life just isn’t worth living. • Life is so bad I feel like giving up. • I just wish my life would end. • It would be better for everyone involved if I were to die. • I feel there is no solution to my problems other than taking my own life. • I have come close to taking my own life Items were scored by direct scoring, and the total score was calculated by finding the sum of 10 items. The total score ranges from 10 to 50. Rudd 39 reported a high internal consistency (Cronbach’s alpha of 0.86) and adequate item-total correlations ( r = 0.45–0.74). The SIS was moderately correlated with the Centre for Epidemiology Studies – Depression Scale ( r = 0.55) and the Beck Hopelessness Scale ( r = 0.49). The SIS has been used in Nigerian studies. For instance, Nkwuda, Ifeagwazi, Nwonyi and Oginyi 41 reported a Cronbach’s alpha of 0.90 among Nigerian undergraduates, while Okeke and Ogbonnaya 42 reported a Cronbach’s alpha of 0.89 among Nigerian prison inmates The GHQ-12 was designed to assess psychological distress. 40 The 12 items of the GHQ-12 are scored on a 4-point severity and frequency scale (0–3). Scores of the items of the GHQ-12 are added to derive the total score of psychological distress. The GHQ-12 has acceptable psychometric properties for the Nigerian population 43 As a measure of psychological distress, 40 the GHQ-12 was used to validate suicidality, which is also a manifestation of psychopathology. The researchers collected data for the study Statistical analysis Data were analysed using the Statistical Package for the Social Sciences (SPSS) version 23 (IBM Corporation, Armonk, New York, United States). Factor analysis was used for the exploratory factor analysis (EFA). Reliability analysis was used to find out the Cronbach’s alpha, Guttman splithalf and Spearman–Brown coefficients. Finally, Pearson correlation analysis was used to determine the congruence validity of the scale under development Results Item generation for the Redeemer’s University Suicidality Scale Figure 1 is a flow chart depicting the steps taken in developing and validating the RUSS. The steps include item generation,

[Find the meaning and references behind the names: Man, Kaiser]

Page 4 of 9 Original Research http://www.sajpsychiatry.org Open Access face and content validity, Item refinement, congruent validity, reliability and norms of the RUSS. The items for the RUSS were based on the symptoms of suicidality (suicide ideation, planning and attempt) found in both the Diagnostic and Statistical Manual of Mental Disorders, 5 th edition (DSM-5), and the International Classification of Diseases, 10 th revision (ICD-10). 44,45,46 Thirty-seven items were generated using three of the sources recommended by Furr (2011) and Streiner (2015). These sources are an examination of items in some instruments that measure suicide, a review of theories of suicide for potential ideas and research findings of previous studies. Clinical features of depression and suicidality in the DSM-5 were also considered 44,45,46 Validity of the Redeemer’s University Suicidality Scale The generated items were subjected to both face validity and content validity assessment by a panel of experts made up of one psychiatrist and six clinical psychologists. The experts reviewed items for content regarding their relevance to the content domain, completeness and accuracy. They also reviewed for item sensitivity to evaluate potential item bias. 47 The items were evaluated using the content validity ratio (CVR) of a four-point scale of 1 = not relevant, 2 = somewhat relevant, 3 = quite relevant but needs rewording and 4 = highly relevant. 48 All items checked as ‘not relevant’ were eliminated. Using 75 % item inclusion (i.e. 75 % of the experts must approve an item for inclusion), those checked as ‘needs rewording’ were reworded, and items checked as highly relevant were retained. Thirty items were retained after CVR. Lastly, the 30 items were re-presented to the experts for review on a two-point response format of ‘yes’ and ‘no’. Items checked as ‘yes’ were included while those checked as ‘no’ were removed. Using the 75 % item inclusion, 25 items were retained. The justification for employing the face validity method was that the expert technique is acceptable for content validity 49 when combined with a comprehensive identification process as outlined above. This process resulted in a final version of 25 valid items used for item refinement Item refinement One hundred and fifty university undergraduates (male, 79; female, 71) were purposively drawn from a Nigerian private university. A cross-sectional method was used to select participants from all levels of study in the seven faculties in the chosen institution. The faculties are Natural Sciences, Social Sciences, Management Sciences, Humanities, Law, Basic Medical Sciences and Engineering. The responses of these participants were used for the EFA (item refinement) of the RUSS. The participants’ ages ranged between 15 and 34 years (mean = 19.72; SD = 3.61) The 25 items of the RUSS were subjected to EFA. Factors with eigenvalues > 1 were extracted at the first stage of EFA. Next, the statistics for factors with eigenvalues > 1 were scrutinised. Stevens 50 recommended 0.40 as the least factor loading. Items having loadings of less than 0.45 were deleted to improve the RUSS interpretability. The different plausible factor solutions were evaluated considering the items’ content and the proportional construct of interest Exploratory factor analysis According to Pallant 51 for factor analysis to be considered appropriate, Bartlett’s test of sphericity (BTS) should be significant ( p < 0.05), with 0–1 range for the Kaiser–Meyer–Olkin (KMO) index and 0.06 set as the minimum value for suitable factor analysis. The results of the tests are presented in Table 1 Table 1 indicates that the KMO measure of sampling adequacy is 0.93, and it is within the recommended range of 0–1. The BTS is significant ( X 2 = 3507.995, degrees of freedom [ df ] = 351, p = 0.000). Therefore, the results support the correlation matrix’s factorability, and hence the principal component analysis (PCA) is conducted. The principal component extraction method’s test indicated four components extracted with eigenvalues > 1, and the summary is presented in Table 2 Item generaon Validity (Face and content) Item refinement (Exploratory factor analysis (EFA)) Norm Congurent validity Reliability (Cronbach's alpha; Gu man split half; Spearman brown coefficient) FIGURE 1 : Flow diagram for the suicidality scale development and validation. TABLE 1: Summary of Kaiser–Meyer–Olkin and Bartlett’s Test of Sphericity on the factorability of the 25-item measure for the Redeemer’s University Suicidality Scale. Measurement Values Bartlett’s Test of Sphericity (BTS) Approximate chi-square 3507.995 df 351 Sig 0.000 KMO measure of sampling adequacy 0.93 KMO, Kaiser–Meyer–Olkin; BTS, Bartlett’s Test of Sphericity; df, degrees of freedom; Sig., significance.

[Find the meaning and references behind the names: Bright]

Page 5 of 9 Original Research http://www.sajpsychiatry.org Open Access Table 3 summarises the principal component matrix analysis showing the extracted four components with eigenvalues above 1 for the 25-item measure for the RUSS. The loading of the 25 items under the four components is presented in Table 3 The four components extracted summarised in Table 3 were because the items loaded on these four components with eigenvalues exceeding 1. The eigenvalues of the four components range from 14.018 to 1.021, with a percentage ranging from 51.918 to 3.782. However, only one dimension was retained, as items in the other three components either loaded more than once, rendering them complex structures or standalone items. The eigenvalues of the included component explained a total of 51.9 % of the total variance Congruent validity of the Redeemer’s University Suicidality Scale Participants Using a cross-sectional method, a fresh sample of 184 purposively selected undergraduates (male, 70; female, 114) were sampled. The participants’ ages ranged between 15 and 34 years (mean = 19.72; s.d = 3.61). Participants were selected from all levels of study in the faculties of Natural Sciences, Social Sciences, Management Sciences, Humanities, Law, Basic Medical Sciences and Engineering. Data collected were used to determine the psychometric properties of the RUSS The RUSS was validated using the congruent validity technique to ascertain its relationship with existing measures: the SIS 39 and the GHQ-12. 40 Significant positive correlation coefficients were observed between the RUSS and the SIS ( r = 0.881, p = 0.000) and between the RUSS and the GHQ-12 ( r = 0.605, p = 0.000). This finding made the RUSS valid as a diagnostic tool for measuring suicidality among the general Nigerian population Reliability of the Redeemer’s University Suicidality Scale Participants A fresh sample of 182 university undergraduates (male, 89; female, 93) was purposively drawn from a Nigerian private university. The participants’ ages ranged between 16 and 31 years (mean = 19.72; s.d = 3.61). A cross-sectional method was used to select the participants from all levels of study in the seven faculties in the chosen institution. The responses of these participants were used to ascertain the reliability of the scale. The 20 items of the RUSS that were extracted from EFA in the item refinement process were administered to the participants. Data were analysed using the SPSS Ethical considerations This study relied on human subjects for its investigation. As a result, the Helsinki Declaration was followed in terms of research ethics for human beings. The research purpose was assessed by Redeemer’s University’s Internal Research Ethics Committee, which advised protocols. The ethical requirements for this type of research are not applicable (National Code of Health Research Ethics; Nigerian National Health Research Ethics Committee) (NHREC). Section B, item A. http:// www.nhrec.net/nhrec/NCHRE 10.pdf Results Values of the corrected item-total correlations (point-biserial) indicated discriminations in the items of the RUSS. Values between 0 and 0.19 imply poor discrimination, 0.2 and 0.39 indicate good discrimination, while ≥ 0.4 suggests very good discrimination. As observed in Table 4, the item with a value between 0 and 0.19 in the RUSS is ‘I do not think killing myself TABLE 3: Component matrix of 25 items of the Redeemer’s University Suicidality Scale Component matrix † Component 1 2 3 4 32. I told someone of my plans to kill myself 0.919 - - - 33. I had tried to kill myself 0.898 - - - 31. I looked for a perfect opportunity to execute my plan for killing myself 0.894 - - - 24. I feel so lonely and unwanted that I want to kill myself to end my misery 0.875 - - - 23. The only option out of my problems is to kill myself 0.875 - - - 30. I have made plans of how to kill myself 0.874 - - - 34. I visited online websites to find suitable ways to kill myself 0.870 - - - 2. I wished I were dead 0.854 - - - 29. I am writing or have written a suicide note 0.831 - - - 18. I see myself as a failure and wish to kill myself 0.827 - - - 25. By and large, life has been cruel to me, so I want to end it myself 0.822 - - - 1. I have thoughts of killing myself 0.817 - - - 8. Life has been unfair; I feel like giving up 0.817 - - - 3. I told someone my thought of killing myself 0.800 - - - 9. I believe my family would be better off if I were dead 0.788 - - - 6. I am sure I will one day kill myself 0.763 - - - 12. The only solution I see to my problems is suicide 0.725 - - - 26. I desire to die 0.698 - - - 20. I do not want to die -0.688 - - - 35. I do not think killing myself would solve my problems -0.558 - - - 4. The future looks bright for me - -0.817 - - 27. Cultural rituals for death by suicide are what is keeping me from killing myself 0.483 0.490 - - 16. I am sure that I have the will to survive - - 0.792 - 28. My religious belief is what is keeping me from ending my life - - 0.466 -0.618 5. I consider suicide morally wrong - - 0.471 0.563 Note: Extraction method is the principal components analysis (PCA). PCA, principal component analysis † 4 components extracted TABLE 2: Total variance explained Components Eigenvalues % of variance Cumulative % 1 14.018 51.918 51.918 2 1.796 6.647 58.566 3 1.489 5.513 64.079 4 1.021 3.782 67.861

Page 6 of 9 Original Research http://www.sajpsychiatry.org Open Access would solve my problems’ (0.12). The observed values of the point-biserial suggest that items with values below the very good discrimination should be deleted from the scale, as this could indicate an ambiguous and confusing item to participants Table 4 further shows the Cronbach’s alpha and the item-total statistics of the 20-item RUSS. The scale achieved a reliability coefficient of 0.93, a Guttman split-half reliability of r = 0.825 and a Spearman–Brown coefficient of r = 0.828 Calculation of norms for the Redeemer’s University Suicidality Scale The cut-off points for the RUSS were determined using the 95 % confidence interval (CI) method. As summarised in Table 5, with 95 % confidence, the group population mean was between 32.6 and 37.7, based on 184 samples (35.13 [95 % CI 32.6–37.7]); the male population mean was between a range of 27.6 and 34.4, based on 70 samples (30.97 [95 % CI 27.6–34.4]); while the derived mean for the female population was between 34.2 and 41.1, based on 114 samples (37.68 [95 % CI 34.2–41.1]). The group and gender categories mean score plus one standard deviation were used to calculate the cut-off points. The result showed ≥ 53, ≥ 46 and ≥ 56 as cut-off points (norm) for the group, male and female samples, respectively The final draft of the validated RUSS and the scores’ interpretations are itemised in Table 6 and Table 7, respectively Item 9 (with ‘ † ’ symbol) is reverse scored. The total score is arrived at by adding up the items’ scores. The higher the score, the greater the severity of suicidal behaviour Table 7 is a summary of the interpretation of the scores based on group and individual samples. The individual samples are categorised by gender Discussions This study is a development and validation of the RUSS. The scale measures suicidal behaviours (suicidal ideation, TABLE 6: The final draft of validated Redeemer’s University Suicidality Scale Items SD MD N MA SA 1. I have thoughts of killing myself 1 2 3 4 5 2. I wished I were dead 1 2 3 4 5 3. I told someone my thought of killing myself 1 2 3 4 5 4. I am sure I will one day kill myself 1 2 3 4 5 5. Life has been unfair; I feel like giving up 1 2 3 4 5 6. I believe my family would be better off if I were dead 1 2 3 4 5 7. The only solution I see to my problems is suicide 1 2 3 4 5 8. I see myself as a failure and wish to kill myself 1 2 3 4 5 9. I do not want to die † 1 2 3 4 5 10. The only option out of my problems is to kill myself 1 2 3 4 5 11. I feel so lonely and unwanted that I want to kill myself to end my misery 1 2 3 4 5 12. By and large, life has been cruel to me, so I want to end it myself 1 2 3 4 5 13. I desire to die 1 2 3 4 5 14. I am writing or have written a suicide note 1 2 3 4 5 15. I have made plans of how to kill myself 1 2 3 4 5 16. I looked for a perfect opportunity to execute my plan for killing myself 1 2 3 4 5 17. I told someone of my plans to kill myself 1 2 3 4 5 18. I had tried to kill myself 1 2 3 4 5 19. I visited online websites to find suitable ways to kill myself 1 2 3 4 5 Note: Instruction: The answer key for the questions can be interpreted as follows 1 = Strongly Disagree (SD) 2 = Mildly Disagree (MD), 3 = Neutral (N), 4 = Mildly Agree (MA) and 5 = Strongly Agree (SA ) † , item is reverse scored TABLE 5: The 95 % confidence interval of cut-off point determination for the Redeemer’s University Suicidality Scale by sex Statistical test Group sample Individual male Individual female Margin of error 2.53 4.39 3.44 Sample size 184 70 114 Sample mean 35.13 30.97 37.68 Standard deviation 17.52 14.54 18.72 95 % CI 32.6–37.7 27.6–34.4 34.2–41.1 Cut-off point ≥ 53 ≥ 46 ≥ 56 CI, confidence interval; RUSS, Redeemer’s University Suicidality Scale TABLE 4: Item-total statistics of the Redeemer’s University Suicidality Scale Reliability statistics Cronbach’s alpha 0.93 N of Items 19 Item-total statistics Scale mean if item deleted Scale variance if item deleted Corrected item-total correlation Cronbach’s alpha if item deleted I have thoughts of killing myself 33.0543 268.686 0.682 0.935 I wished I were dead 33.1848 267.583 0.792 0.933 I told someone my thought of killing myself 33.2717 272.942 0.674 0.935 I am sure I will one day kill myself 33.5870 281.359 0.708 0.935 Life has been unfair; I feel like giving up 32.7391 271.932 0.675 0.935 I believe my family would be better off if I were dead 33.2283 270.756 0.758 0.934 The only solution I see to my problems is suicide 33.5978 279.936 0.759 0.935 I see myself as a failure and wish to kill myself 33.4348 273.996 0.779 0.934 I do not want to die 33.1957 284.901 0.431 0.940 The only option out of my problems is to kill myself 33.8043 286.672 0.710 0.936 I feel so lonely and unwanted that I want to kill myself to end my misery 33.3261 269.642 0.799 0.933 By and large, life has been cruel to me, so I want to end it myself 33.5761 277.994 0.777 0.934 I desire to die 33.3913 272.043 0.792 0.933 I am writing or have written a suicide note 33.5109 280.404 0.617 0.936 I have made plans of how to kill myself 33.2935 274.963 0.654 0.936 I looked for a perfect opportunity to execute my plan for killing myself 33.5217 279.180 0.628 0.936 I told someone of my plans to kill myself 33.5435 279.637 0.610 0.937 I had tried to kill myself 33.3696 276.497 0.635 0.936 I visited online websites to find suitable ways to kill myself 33.7826 289.592 0.485 0.938 I do not think killing myself would solve my problems 33.0652 297.635 0.126 0.947

[Find the meaning and references behind the names: Main, Lynn]

Page 7 of 9 Original Research http://www.sajpsychiatry.org Open Access suicide planning and suicide attempts) among the general population. From gap identification to norming, seven steps were used in the development process of the RUSS. Different sources had proposed various steps in the scale development process. For instance, Lynn 52 proposed a two-stage strategy. The first step included generating an initial pool, and the second stage involved validation (evaluation of the instrument’s item performance). Crocker and Algina 53 and Price 54 both proposed 11 steps; Furr 55 proposed five steps; Streiner et al 56 proposed seven steps, while DeVellis 57 proposed eight steps. Four main features are common in most of these studies: item generation, item refinement, reliability studies and validity studies. The development process of the RUSS followed these steps The DSM-5 and the ICD-10 were used to review clinical aspects of suicidal behaviour (ideation, intent and planning). 44,45,46 The generation of items relating to the agreed themes resulted in 37 items used for scale purification purposes. Because of the RUSS’s ability to measure opinions, beliefs and attitudes, a six-point Likert scale was utilised. In other words, each RUSS item is a declarative statement, hence the decision to employ a Likert answer format. 57 The RUSS purification was carried out using a combination of reliability analysis and EFA, as proposed by Flynn and Pearcy 58 and Pecheux and Derbaix. 59 A team of specialists checked the content validity of the initial items generated by the authors. According to Streiner et al., 48 content validity represents current knowledge in the construct of interest. It is also a vital sign of an instrument’s validity and shows how viable and practicable it is 60 The development of the RUSS provided a foundation for further investigation of its validity and reliability. Cronbach’s alpha was 0.93, and item-total correlation was 0.13–0.79. This finding implies a good item inter-relatedness, unidimensionality and homogeneity of the construct 61,62 among the Nigerian population. To put it another way, the Cronbach’s alpha, Spearman–Brown coefficient and Guttman split-half coefficient scores were not too high to make some items redundant. 63,64 In conclusion, the high alpha score indicates that the RUSS has a high level of reliability. The RUSS was verified using the concurrent validity approach, as Cronbach and Meehl 65 advised. Two standardised scales, one each for assessing suicidal ideation and psychological distress in the general population, were positively linked with the RUSS. The RUSS is a suitable measure of suicidal behaviour for adolescents and adults in Nigeria and other climes with similar sociocultural circumstances, based on its EFA and acceptable psychometric qualities Conclusion and recommendations The RUSS was created by extracting a single-factor scale with 20 items through initial item generation, expert appraisal (face and content validity) of the initial pool of items and EFA for item purification. Internal consistency (reliability coefficient) of the RUSS items is acceptable. The SIS and the GHQ-12 had strong positive correlations with the RUSS, indicating a satisfactory congruent validity coefficient Based on the findings of this study, the 19-item RUSS showed good internal consistency and validity scores to measure suicidal behaviour. This analysis indicates that the RUSS is reliable and valid for the Nigerian population. Norms for the group and individual (male and female) samples are indications that the scale is gender-sensitive and can be selfadministered both individually and in group studies. Therefore, it is recommended as a diagnostic tool for suicidal behaviour among adolescents and adults in clinical settings. It can also be used to measure suicidality in group research settings to provide information on suicidal behaviour among the general public to enable policymaking in mental healthcare domains. Again, taking into cognisance the Nigerian sociocultural setting in its item generation and development, the RUSS is recommended not only for Nigerian use but also for use in countries with similar sociocultural situations Limitations of the study This study was conducted in the context of the Nigerian population’s distinct psychosociocultural environment. Without scale revalidation, generalising the findings and using this scale on other populations with different sociocultural traits should be addressed with caution Acknowledgements Competing interests The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article Authors’ contributions B.C.A. conceptualised the project, designed the study, wrote the protocol of the study, wrote the first draft of the manuscript and managed the literature search and analysis of the data and methodology. E.O.A. supervised the project, wrote the first draft of the manuscript and managed the analyses of the study. A.O.O. managed data collection and review of literature for the study. D.O.K. managed the literature searches for the study and reviewed the manuscript TABLE 7: Interpretation of Redeemer’s University Suicidality Scale scores Scoring Group sample Individual male sample Individual female sample Normal 0–18 0–17 0–19 Mild suicidal behaviour 19–52 18–45 20–56 Moderate suicidal behaviour 53–69 46–60 57–75 Severe suicidal behaviour 70 and above 61 and above 75 and above

[Find the meaning and references behind the names: Zhang, Lee, Williams, June, Lopez, Moreno, Wang, Martin, Leo, Liang, Kalai, Low, Scott, Sun, Alexis, Grant, Don, Med, Nixon, Nelson, Arafat, Dimitrov, Miranda]

Page 8 of 9 Original Research http://www.sajpsychiatry.org Open Access Funding information This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors Data availability Data sharing is not applicable to this article as no new data were created or analysed in this study Disclaimer The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors References 1. World Health Organization. Mental health, suicide data [homepage on the Internet]. 2019 [cited 2021 Aug 24]. Available from: https://www.who.int/ mental_health/prevention/suicide/suicideprevent/en/ 2. Center for Disease Control and Prevention (CDC). Web-based Injury Statistics Query and Reporting System (WISQARS) [homepage on the Internet]. Atlanta, GA: National Center for Injury Prevention and Control; 2020 [cited 2022 June 20]. Available from: https://www.cdc.gov/injury/wisqars/index.html 3. World Health Organization. Suicide in the world: Global health estimates [homepage on the Internet]. 2019 b [cited 2021 July 03]. Geneva: World Health Organization, p. 1–33 4. Shuchman M. Suicide report indicates shift at WHO. CMAJ. 2014;186:E 532. https://doi.org/10.1503/cmaj.109-4897 5. Gong Y, Zhang, L, Wang, Z, Liang, Y. Pathway analysis of risk factors for severe suicidal ideation: A survey in rural China. Can J Public Health. 2011;102(6):472– 475. https://doi.org/10.1007/BF 03404203 6. Fleischmann A, De Leo D. The World Health Organization’s report on suicide: A fundamental step in worldwide suicide prevention. Crisis. 2014;35:289–291. https://doi.org/10.1027/0227-5910/a 000293 7. Mental Health first aid. Suicide vs. self-injury: Knowing the difference and how to get help [homepage on the Internet]. 2020 [cited 2022 June 20]. Available from: https://www.mentalhealthfirstaid.org/2020/03/suicide-vs-self-injury-knowingthe-difference-and-how-to-get-help/ 8. Hillside. Non-suicidal vs. suicidal self-harm. 2021 [cited 2022 June 20]. Available from: https://hside.org/non-suicidal-vs-suicidal-self-harm/ 9. Miranda R, Ortin A, Scott M, Shaffer D. Characteristics of suicidal ideation that predict the transition to future suicide attempts in adolescents. J. Child Psychol Psychiatry. 2014;55(11):1288–1296. https://doi.org/10.1111/jcpp.12245 10. Harmer B, Lee S, Duong T, Saadabadi A. Suicidal ideation. Florida, FL: StatPearls Publishing; 2021. 11. Silverman MM, Berman AL, Sanddal ND, O’carroll PW, Joiner TE. Rebuilding the tower of Babel: A revised nomenclature for the study of suicide and suicidal behaviors. Part 2: Suicide-related ideations, communications, and behaviors. Suicide Life Threat Behav. 2007;37(3):264–277. https://doi.org/10.1521/ suli.2007.37.3.264 12. Parellada M, Saiz P, Moreno D, et al. Is attempted suicide different in adolescent and adults? Psychiatry Res. 2008;157(1–3):131–137. https://doi.org/10.1016/j. psychres.2007.02.012 13. Cloutier P, Martin J, Kennedy A, Nixon MK, Muehlenkamp JJ. Characteristics and co-occurrence of adolescent non-suicidal self-injury and suicidal behaviours in pediatric emergency crisis services. J Youth Adolesc. 2010;39(3):259–269. https:// doi.org/10.1007/s 10964-009-9465-1 14. Klonsky ED, May AM. The Three-Step Theory (3 ST): A new theory of suicide rooted in the ‘ideation-to-action’ framework. Int J Cognitive Ther. 2015;8(2):114–129. https://doi.org/10.1521/ijct.2015.8.2.114 15. Vilhjalmsson R, Kristjansdottir G, Sveinbjarnardottir E. Factors associated with suicide ideation in adults. Soc Psychiatry Psychiatr Epidemiol 1998;33(3):97–103. https://doi.org/10.1007/s 001270050028 16. De Leo D, Burgis S, Bertolote J, Kerkhof AM, Bille-Brahe U. Definitions of suicidal behavior. In: De Leo D, Bille-Brahe U, Kerkhof ADM, Schmidtke A, editors. Suicidal behavior: Theories and research findings. Washington, DC: Hogrefe & Huber, 2004; p. 17–39 17. Klonsky ED, May Alexis M, Saffer Boaz Y. Suicide, suicide attempts, and suicidal ideation. Clin Psychol. 2016;12:307–330. http://doi.org/10.1146/annurevclinpsy-021815-093204 18. Sareen J, Cox BJ, Afifi TO, De Graaf R, Asmundson GJ, Ten HM. Anxiety disorders and risk for suicidal ideation and suicide attempts: A population based longitudinal study of adults. Arch Gen Psychiatry. 2005;62(11):1249–1257 19. Very Well Mind. What is suicidal ideation? A look at dangerous thought patterns [homepage on the Internet]. 2020 [cited 2022 June 20]. Available from: https:// www.verywellmind.com/suicidal-ideation-380609 20. Groleger U, Tomori M, Kocmur M. Suicidal ideation in adolescence – An indicator of actual risk? Isr J Psychiatry Relat Sci 2003;40(3):202–208 21. Cluver L, Orkin M, Boyes ME, Sherr L. Child and adolescent suicide attempts, suicidal behavior, and adverse childhood experiences in South Africa: A prospective study. J Adolesc Health. 2015;57(1):52–59. https://doi.org/10.1016/j. jadohealth.2015.03.001 22. Evans E, Hawton K, Rodham K. In what ways are adolescents who engage in selfharm or experience thoughts of self-harm different in terms of help-seeking, communication and coping strategies? J Adolesc. 2005;28:573–587. https://doi. org/10.1016/j.adolescence.2004.11.001 23. Mars B, Burrows S, Hjelmeland H, et al. Suicidal behaviour across the African continent: A review of the literature. BMC Public Health. 2014;14:1–14. https:// doi.org/10.1186/1471-2458-14-606 24. Rukundo GZ, Byakwaga H, Kinengyere A, et al. Prevalence and factors associated with suicide among medical professionals in low/middle-income countries: A systematic review protocol. BMJ Open. 2019;9:e 028884. https://doi.org/10.1136/ bmjopen-2018-028884 25. Azoma C. Suicide: Doctors at risk. The SUN: Voice of the Nation [newspaper online]. 2017 Sept 7 [cited 2022 June 20]. Available from: https://www. sunnewsonline.com/suicide-doctors-at-risk/ 26. Ukwu J. 7 Nigerian states with high suicide cases [homepage on the Internet]. 2016 [cited 2022 June 20]. Available from: https://www.legit.ng/971791- recession-7-nigerian-states-unbelievably-high-suicide-cases.html 27. World Bank – World Development Indicators. World Health Organization, global health observatory data repository. 2016 [cited 2022 June 20]. Available from: http://apps.who.int/ghodata/ 28. Goldberg E. Rural areas have the highest suicide rates and fewest mental health workers, business. HuffPost. 2018. Available from https://www.huffpost.com/ entry/rural-suicide-rates-mental-health_n_5 b 22 dd 28 e 4 b 0 d 4 fc 01 fcc 098 29. World Health Organization. Preventing suicide: A global imperative [homepage on the Internet]. 2014 [cited 2021 Aug 10]. Available from: https://www.who.int/ publications/i/item/preventingsuicide-a-global-imperative 30. Alabi O, Alabi A, Ayinde O, et al. Suicide and suicidal behavior in Nigeria: A review. Psychiatry J. 2014;37:1–6 31. THISDAY newspaper. Floating a new crusade against suicide. THISDAY. [homepage on the Internet], 2018 [cited No date]. Available from https://www.thisdaylive. com/index.php/2018/09/13/floating-a-new-crusade-against-suicide/ 32. Oyetunji TP, Arafat SMY, Famori SO, et al. Suicide in Nigeria: Observations from the content analysis of newspapers. Gen Psychiatry. 2021;34:e 100347. https://doi. org/10.1136/gpsych-2020-100347 33. Ohayi SR. ‘Doctor, please don’t say he died by suicide’: Exploring the burden of suicide survivorship in a developing country. Egypt J Forensic Sci. 2019;9:3–9. https://doi.org/10.1186/s 41935-019-0153-3 34. Glenn ID. Sampling the evidence of extension program impact. Program Evaluation and Organizational Development, IFAS, University of Florida; 1992. Available from https://edis.ifas.ufl.edu/publication/PD 005#TOP 35. Villarroel MA, Terlizzi EP. Symptoms of depression among adults: United States, 2019. NCHS Data Brief, no 379. Hyattsville, MD: National Center for Health Statistics; 2020 36. Akpunne BC, Uzonwanne FC. Problematic smartphone uses as a predictor of depression, anxiety and psychological distress among undergraduate students in four selected Nigerian Universities. J Commun Media Res. 2020;12(2):92–103 37. Dabana A, Gobir AA. Depression among students of a Nigerian University: Prevalence and academic correlates. Arch Med Surg [serial online]. 2018 [cited 2022 June 20]. Available from: https://www.archms.org/text.asp?2018/ 3/1/6/243037 38. Guedria-Tekari A, Missaoui S, Kalai W, Gaddour N, Gaha L. Suicidal ideation and suicide attempts among Tunisian adolescents: Prevalence and associated factors. Pan Afric Med J. 2019;34:105. https://doi.org/10.11604/pamj.2019. 34.105.19920 39. Rudd MD. The prevalence of suicidal ideation among college students. Suicide Life Threat Behav 1989;19(2):173–183. https://doi.org/10.1111/j.1943-278 X.1989. tb 01031.x 40. Goldberg DP, Williams P. A user’s guide to the General Health Questionnaire. Glasgow: NFER-NELSON Publishing Company; 1991. 41. Nkwuda FCN, Ifeagwazi CM, Nwonyi SK, Oginyi RC. Suicidal ideation among undergraduate students: Academic stress and self-esteem as predictive factors. Nigerian J Psychol Res. 2020;16(1):55-64. 42. Okeke AO, Ogbonnaya CE. Personality dimensions as predictors of suicidal ideation among selected prison inmates in Anambra State, Nigeria: A demographical perspective. Asian J Med Health. 2019;17(1):1–10. https://doi. org/10.9734/ajmah/2019/v 17 i 130155 43. Akpunne B, Akinnawo O. Internet addiction, problematic smartphone use and psychological health of Nigerian University Undergraduates. Int Neuropsychiatric Dis J. 2019;12(3):1–13. https://doi.org/10.9734/indj/2018/v 12 i 330093 44. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5 th ed. Washington, DC: American Psychiatric Association; 2013 45. Carr A. Clinical psychology: An introduction. London: Routledge; 2012. 46. Bech P. Clinical features of mood disorders and mania. In Gelder MG, Andreasen NC, Lopez—Ibor JJ, Geddes Jr., JR., editors. New Oxford textbook on psychiatry. 2 nd ed. Volume 1, Oxford: Oxford University Press, 2009; p. 632–637 47. Dimitrov DM. Statistical methods for validation of assessment scale data in counseling and related fields. Alexandria, VA: American Counseling Association; 2012.

[Find the meaning and references behind the names: Watanabe, Davis, Ang, Mak, Wright, Lai, Norman, Market]

Page 9 of 9 Original Research http://www.sajpsychiatry.org Open Access 48. Waltz CW, Bausell RB. Nursing research: Design, statistics and computer analysis. Philadelphia, PA: F.A. Davis; 1981 49. Nunnally JC. Psychometric theory. 2 nd ed. New York, NY: McGraw-Hill; 1978. 50. Stevens JP. Applied multivariate statistics for the social sciences. New York, NY: Routledge; 2009 51. Pallant J. SPSS survival manual. 2 nd ed. New York, NY: Open University Press; 2005. 52. Lynn MR. Determination and quantification of content validity. Nurs Res. 1986;35:382–385. https://doi.org/10.1097/00006199-198611000-00017 53. Crocker L, Algina J. Introduction to classical and modern test theory. New York, NY: Holt, Rinehart & Winston; 1986 54. Price LR. Psychometric methods: Theory into practice. New York, NY: The Guilford Press; 2017 55. Furr RM. Scale construction and psychometrics for social and personality psychology. New Delhi: Sage; 2011 56. Streiner DL, Norman GR, Cairney J. Health measurement scale: A practical guide to their development and use. 5 th ed. England: Oxford University Press; 2015 57. DeVellis RF. Scale development: Theory and applications. Applied social research methods series. Vol. 26. 2 nd ed. Thousand Oaks, CA: Sage; 2003 58. Flynn LR, Pearcy D. Four subtle sins in scale development: Some suggestions for strengthening the current paradigm. Int J Market Res. 2001;43(4):1–14. https:// doi.org/10.1177/147078530104300404 59. Pecheux C, Derbaix C. Mood and children: Proposition of a measurement scale. J Econ Psychol. 1999;20(5):571–590. https://doi.org/10.1016/S 0167-4870(99) 00025-2 60. DeVon HA, Block ME, Moyle-Wright P, et al. A psychometric toolbox for testing validity and reliability. J Nurs Scholarsh. 2007;39:155–64. https://doi.org/10.1111/ j.1547-5069.2007.00161.x 61. Bland J, Altman D. Statistics notes: Cronbach’s alpha. BMJ. 1997;314:275. https:// doi.org/10.1136/bmj.314.7080.572 62. Streiner D. Starting at the beginning: An introduction to coefficient alpha and internal consistency. J Pers Assess. 2003;80:99–103. https://doi.org/10.1207/ S 15327752 JPA 8001_18 63. Lai CM, Mak KK, Watanabe H, Ang RP, Pang JS, Ho RC. Psychometric properties of the internet addiction test in Chinese adolescents. J Pediatr Psychol. 2013;38(7):794–807. https://doi.org/10.1093/jpepsy/jst 022 64. Panayides P Walker MJ. Evaluation of the psychometric properties of the Internet Addiction Test (IAT) in a sample of Cypriot High School students: The Rasch measurement perspective. Eur J Psychol. 2012;8(3):327–351. https://doi. org/10.5964/ejop.v 8 i 3.474 65. Cronbach LJ, Meehl PE. Construct validity in psychological tests. Psychol Bull. 1955;52(4):281–302. https://doi.org/10.1037/h 0040957

Other Psychiatry Concepts:

[back to top]

Discover the significance of concepts within the article: ‘Development and validation of the Redeemer’s University Suicidality Scale’. Further sources in the context of Psychiatry might help you critically compare this page with similair documents:

Mental health, Mental disorder, Mental illnesses, Religious belief, Cultural rituals, Suicide, Original research, Statistical analysis, Assessment, Statistical test, Inclusion criteria, Exclusion criteria, Sample size, Ethical consideration, General population, Study setting, Study sample, Cronbach's alpha, Social isolation, Psychological distress, Diagnostic tool, Psychometric properties, Content validity, Confidence interval, Principal component analysis, Standard deviation, Item generation, Risk factor, Research Method, Face Validity, Internal Consistency, Exploratory Factor Analysis, Cut-off point, Underlying disease, Risk identification, Research Ethics, Suicidal behavior, Clinical setting, Suicidal ideation, Reliability coefficient, Statistical package, Nigerian population, Leading cause of death, Item refinement, Item analysis, Suicidal behaviour, Bartlett's Test of Sphericity, Suicide rate, Concurrent validity, Content Validity Ratio, Suicide prevention, Item-total correlation, Margin of error, Suicide attempt, Sample mean, International Classification of Disease, Corrected item-total correlation, Suicide note, Suicide ideation, Suicide death, Mental healthcare, Creative Commons Attribution License, Undergraduate student, Sociocultural setting, Diagnostic and Statistical Manual of Mental Disorder, Suicide plan, Scale mean.