Title page: psychometric properties of literacy of suicide scale (LOSS) in iranian population: long form
BMC Public Health volume 23, Article number: 608 (2023)
Suicide and suicide attempts are among the most important indicators of mental health in the world. In this research, the validity and reliability of Literacy of Suicide Scale (LOSS) was examined in general people over the age of 18.
This cross-sectional psychometric study was conducted in 2022 among 952 general population in Iran. Participants were selected by two methods of proportional stratified sampling and simple random sampling. The internal consistency of the tools was assessed using Cronbach’s alpha coefficient, and McDonald omega coefficient. Also, test-retest reliability was checked by Intraclass Correlation Coefficient (ICC).
In the confirmatory factor analysis section, the factor loading of all questions were above 0.4 and one questions were deleted and final model with four factors and 25 questions was confirmed (Some of goodness-of-fit indexes: AGFI = 0.910, RMSEA = 0.050, IFI = 0.901, and χ2/df = 3.333). For all questions, the Cronbach’s alpha coefficient was 0.859, McDonald omega coefficient was 0.866, and ICC was 0.895. Finally, the Persian long version of LOSS was approved with 25 items and four subscales: causes/triggers (9 items), risk factors (7 items), signs and symptoms (5 items) and treatment/prevention (4 items).
The Persian long version of LOSS with four subscales and 25 items is an appropriate tool to investigate the state of suicide literacy in the public population.
Suicide is a conscious act that leads to death . Suicide and suicide attempt are an important issue of public concern. In other words, suicide and suicide attempt are among the most important indicators of mental health for individuals in society . The number of suicides has been on the rise over the past 50 years, and in many countries actual suicide rates are not published due to cultural and ethnic concerns .
According to the results of the 2020 systematic review, the prevalence of suicide beliefs in the general population was 12.9%, with 15.8% among women and 5.2% among men. Also, the prevalence of suicide was 8.8% after a disaster . The results of another systematic review in 2020 showed that the prevalence of suicide beliefs ranged from 9.7 to 58.3%, and the suicide rate ranged from 0.7 to 14.7% .
The results of a study in Iran showed that suicide rates are high, with most suicides occurring between the ages of 20 and 29 . Health literacy is one of the variables that affects people’s behavior . High health literacy has many benefits such as prevention, early diagnosis and intervention in the early stages, and reduced symptoms related to the disease . Suicide literacy is part of mental health literacy and is defined as an understanding of warning signs/ symptoms, causes/ triggers, risk factors, and treatment/prevention . About 80% of those who commit suicide showed signs and symptoms before acting. These results demonstrate the need for suicide literacy in the community and suggest that increasing suicide literacy in the community can help prevent these behaviors . These symptoms are associated with talks about suicide, has a problem in eating or sleeping, experience severe changes in behavior, exit from social activities or friends, gives you its valuable assets, have already committed suicide, takes unnecessary risks, busy with the thought of death and dying, increases the use of alcohol or drugs, loses his interest in his personal appearance .
Low literacy in suicide refers to limited public knowledge about suicide, and this low level of literacy can affect people with suicide thoughts or behaviors . Scientific evidence suggests that individuals with misconceptions about risk factors, treatments, and symptoms of suicide behavior may be at risk for suicide thoughts or behavior . Low awareness of suicide also hinders access to specialized mental health services . Another study showed a positive significant correlation between suicide literacy and seeking psychological help, and increased levels of suicide literacy can increase help seeking . The results in studies in different countries have shown that the rate of suicide literacy is low [14,15,16,17].
Appropriate tools are needed in order to examine individual conditions in different domains and to design and implement appropriate educational and interventional programs . In Iran, no instrument was observed to examine the state of suicide literacy. One of the best tools for examining suicide literacy is a questionnaire designed by Calear et al. The questionnaire contains 26 questions that evaluate people’s knowledge of suicide and in four areas, including signs/ symptoms of suicide, causes/ triggers, risk factors, treatment and prevention . This tool has been evaluated in several studies in different countries [13, 16, 20,21,22,23]. Due to the lack of appropriate suicide literacy tools in Iranian community and the need for availability of this scale, this psychometric study was conducted among general population in Iran.
This cross-sectional study assessed the psychometric properties of long version of LOSS among 954 Iranian public participants in Gonabad city in 2022.
In factor analysis, sample size of 100, 200, 300, 500, 1000 and more are consider poor, fair, good, very well, and excellent, respectively [24, 25]. In the CFA section, the sample size of 954 participants was chosen to assess CFA.
In this study, two methods of proportional stratified sampling and simple random sampling were used for the selection of participants. At first, the number of health care centers and their population in Gonabad city was identified. Any healthcare center is then considered a stratum, and within each stratum, participants are selected by simple random sampling. Inclusion criteria of age over 18 years, no cognitive problems, residency in Gonabad city for more than one year and informed consent were considered in selecting the participants.
Demographic section: In this section, issues such as marital status, age, occupation, sex, and education level were examined.
Literacy of Suicide Scale (LOSS-26): The long version of LOSS was designed and assessed by Calear et al. This scale consists of 26 questions that survey the people’s knowledge of suicide and in four dimensions of signs and symptoms (5 items), causes/ triggers (10 items), risk factors (7 items), and treatment and prevention (4 items) . The questions are measured as “true”, “I don’t know” and “false”. Each question has a correct answer and each answer is awarded one point. To the each “wrong answer” and “I do not know answer” the zero score and to each “correct answer” one score are assigned. In view of the fact that 1 question was finally deleted in this study, the questionnaire was determined to be 25 questions, and the item scores ranged from 0 to 25, with high scores indicating good suicide literacy.
Translation/ cultural adaptation section
This part was checked by WHO Guideline . Before translated the tool, from the designer of the questionnaire, got permission. First, the original English version of LOSS was translated into Persian by two psychologists and health education and health promotion, and the two translated scale were compared and a single Persian version of the LOSS was created. In the next step, the Persian version of the LOSS was translated into English by two experts and then compared with the original English version of the LOSS. After that, the English version was translated into Persian and the final Persian version of LOSS was created.
Based on the source, quantify of content validity and quantify of face validity are not required for standard questionnaires . Because in this study, the LOSS is a standard questionnaire, only quality method was used for evaluation the face and content validity. To investigate the quality content face method, the final version of Persian was examined in terms of the desirability of the expressions in terms of clarity (use of simple and understandable words), the use of a common language (avoiding technical and specialized words). To investigate the quality content validity method, the questionnaire was examined by the specialists in terms of grammar compliance, the use of appropriate words, the importance of items, the placement of items in their proper place, the time to complete the designed tool.
The software of AMOS V.24 was used to evaluate the CFA. Before the running the CFA, the Mahalanobis test was used to determine the outlier’s data and eliminate inappropriate data. Also, kurtosis and skewness tests were used to check the normality of the data. The final model was assessed by using the goodness of fit indexes of RMSEA (root mean square error of approximation), IFI (incremental fit index), PCFI (parsimony comparative fit index), GFI (goodness of fit index), PGFI (parsimony goodness of fit index), CFI (comparative fit index), χ2/df (chi-square ratio to degree of freedom), AGFI (adjusted goodness of fit index), and PNFI (parsimonious normed fit index) [29,30,31]. Standard indexes to confirm the final model are RMSEA less than 0.08, χ2/df less than 5, PNFI, PGFI, and PCFI more than 0.5, CFI, IFI, and GFI more than 0.9, and AGFI more than 0.8 [29,30,31,32].
SPSS software version 20 was used to survey the internal consistency (Cronbach’s alpha coefficient). For internal reliability, a range score between 0.70 and 0.95 is acceptable [33, 34]. The McDonald’s omega coefficient was checking by using JASP (Version .0.11.1). In this study, 30 participants were selected to assess test-retest reliability (twice, over a one-month period). To check test-retest reliability, the Intraclass correlation coefficient (ICC) was used, and ICC > 0.80 is acceptable . For calculation the ICC, the model of Two- Way Mixed and type of Absolute Agreement were used.
The mean (± standard deviation) age of people was 33.35 (± 12.96). Most of people were married (n = 532, 55.9%) and female (n = 501, 88.9%). The occupational status of most people were university students (n = 375, 39.4%), employed (n = 250, 26.3%), and self-employed (n = 136, 14.3%), respectively. The educational level of the majority was a bachelor’s degree (n = 350, 36.8%) and a diploma (n = 265, 27.8%). Additional demographic information is included in Table 1.
Qualitative face validity and content validity were evaluated by 8 exerts (Psychologist and health education and promotion) and also by some participants. In this section, 5 questions were modified.
Based on the results, all goodness-of-fit indexes were acceptable (for example: χ2/df = 3.333, RMSEA = 0.050, IFI = 0.901, AGFI = 0.910) (Table 2). In this section, the factor loading of all questions were above 0.4 and only one question (S10: A person who suicides is mentally ill) was deleted and final model with four factors and 25 questions was confirmed (Table 3; Fig. 1, Table S1).
For all questions of LOSS (25 items), the Cronbach’s alpha coefficient was 0.859 and McDonald omega coefficient was 0.866. In test-retest, for all questions ICC was 0.895. Reliability results for causes/triggers, risk factors, signs/symptoms, and treatment/prevention are mentioned in Table 4. Based on the results of Table 5, there was a significant positive correlation between all subscales (p < 0.001) (Table 5).
Based on a literature review, no psychometric studies of LOSS have been investigated in Iranian populations. The original LOSS questionnaire consisted of 26 questions, in this study, 1 item was removed after evaluation, and the modified Persian version was confirmed as 25 items and 4 factors. Based on the results, the Persian version appears to be useful for measuring LOSS for age groups of different literacy levels in the community.
Previous studies suggest that the McDonald’s omega coefficients provide a more accurate approximation of scale reliability and is a more reasonable indicator than internal compatibility than Cronbach’s alpha. Therefore, when creating a new criterion, the reliability coefficient above 0.70 is considered acceptable [36, 37]. In this study, the Omega McDonald coefficient and Cronbach’s alpha coefficient were used to measuring the reliability of the instrument, which were appropriated values 0.866 for McDonald’s omega coefficients and 0.859 for Cronbach’s alpha. Also, the ICC rate for all questions is 0.895, which is acceptable. Although there is no similar study examining the psychometric characteristics of LOSS in Iran, but in Rafati study, only the psychometric characteristics of another questionnaire designed to examine social attitudes to suicide were examined. In Rafati study, the Persian version of the Social Attitudes to Suicide Questionnaire was validated and Cronbach’s alpha (0.94), McDonald’s omega coefficients (0.943) and ICC index (0.998) were acceptable .
In our study and in the CFA stage, one question was deleted from the original version and the final version of the Persian LOSS was confirmed with 25 questions and four factors of causes/ triggers (9 questions), risk factors (7 questions), sign/symptoms (5 questions), and treatment/ prevention (4 questions). One of the reasons for deleting item S10 (“A person who suicides is mentally ill”) may be that the concept of this issue is not easily understood by the Iranian public unless. On the other hand, the concept and meaning of item S10 is somewhat similar to item 11, and it can even be said that item S11 is easier for Iranian people to understand than item S10.
In a study, the Malaysian version of the LOSS with the Rasch model was validated with a one-dimensional scale and 26 items . The difference in dimensionality can be attributed to the model used, since one of the assumptions of the model is that it is one-dimensional. As can be seen in our study, all the dimensions of the main questionnaire were confirmed, although one question was removed from the final version.
According to the results of the Öztürk study, the Turkish version of LOSS based on Item Response Theory showed a single subscale with an ICC calculation of 0.87 . Therefore, the observed difference is somewhat justified and due to the differences between the models used. In the Chan study in the Australian medical students, Cronbach’s alphabet was reported 0.71 for LOSS questionnaire .
Studies that investigated the process of suicide and its death over five years in southern Iran showed that the suicide process had increased during the period under investigation in the general population  as well as adolescents , and the elderly . Therefore, given the importance of the suicide and the use of this tool in other countries [18, 20, 23], this valid and reliable instrument can be used to determine the status of suicide literacy of the Iranian population and take necessary preventive programs if needed.
Strengths and limitation
Limitations of this study include changes and reductions in the number of questions of the modified Persian version of the questionnaire compared to the original version, resulting in changes in the questionnaire scores. One of the strengths of this study is the use of a high sample size and examination in public population from different age and social groups. Another limitation of this study is that school-age students (15 to 18 years old) were not included in the study, therefore, this may reduce the external validity of the study.
The Persian long version of LOSS with four subscales and 25 items is a valid and reliable instrument. Therefore, given the number of appropriate questions and ease of use, it will be used to investigate the status of suicide literacy in different populations and different groups and finally, help health decision makers design and implement appropriate intervention programs if necessary.
All data generated or analysed during this study are included in this published article.
- LOSS :
Literacy of Suicide Scale
- CFA :
Confirmatory factor analysis
- F1 :
- F2 :
- F3 :
Signs and symptoms
- F4 :
- PCFI :
parsimony comparative fit index
- AGFI :
Adjusted goodness of fit index
- GFI :
Goodness of fit index
- IFI :
Incremental fit index
- RMSEA :
Square error of approximation
- PNFI :
Parsimonious normed fit index
- PGFI :
Parsimony goodness-of-fit index
- x2/df :
Chi-square ratio to degree of freedom
- CFI :
Comparative fit index
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We would like to thanks to Social Development and Health Promotion Research Center, Gonabad University of Medical Sciences. Also, we would like to thanks all people who assisted the authors to run this research project.
This study was received financial support from Social Development and Health Promotion Research Center, Gonabad University of Medical Sciences.
The authors declare that they have no competing interests.
Ethics approval and consent to participate
This study is based on a research project approved by Ethics Committee of Gonabad University of Medical Sciences with the code of ethics IR.GMU.REC.1401.090. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable. Written Informed Consent was obtained from all subjects.
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Jafari, A., Moshki, M., Mokhtari, A.M. et al. Title page: psychometric properties of literacy of suicide scale (LOSS) in iranian population: long form. BMC Public Health 23, 608 (2023). https://doi.org/10.1186/s12889-023-15528-8
- Literacy of suicide
- Health literacy suicide
- Public population