Development and validation of a questionnaire to measure association factors with suicide

Objective: Our goal is to develop an online questionnaire to survey the prevalence of suicidal behavior. Methods: We developed a questionnaire with 51 variables and proceeded with validations. Validations were performed using face validity, content validity, and construct validity. Reliability was performed by test-rest. Results: The face validity was 1.0 and the content validity was 0.91. The exploratory factor analysis got KMO = 0.86 and extracted one principal factor. The confirmatory factor analysis demonstrates RMSEA= 0.000 and CFI=1.000. The test-retest had an intraclass correlated coefficient of 0.98. Conclusion: The adequate development questionnaire was validated, and we have an instrument to survey suicide behaviors in the pandemic time.


-Introduction
Alarmed by the constant and raising notices of suicide occurrences in Marilia in the past 4 years and by the inefficiency of every collective method of prevention used so far, it's noticed the need to perform a better study on the subject. It's known that suicide is an event of complex treatment in general and is related to many mental disorders such as depression, bipolar disorders, panic disorders, schizophrenia, personality disorders, and mental disorders correlated to substance abuse or dependence, and others.(1) According to World Health Organization, 800,000 people committed suicide in the year 2015. (2) In Brazil, in that same year, there were 10,000 suicides, which is much lower (5/100,000 inhabitants) than European countries (20/100,000 inhabitants). (3,4) The Brazilian cities that were described as having the highest risk of suicide in this same period were Taipas do Tocantins, in the State of Tocantins Many questionnaires were found to assess the risk of suicide in the community.
However, we believe that none of them present in all of their items the security to apply the questionnaire remotely and the completeness of our questions. (5) Considering that no investigative instruments that can be fully replicated were found, a questionnaire was created. The questionnaire will address four life dimensions that may be related to the risk of suicide, what are the history of illnesses (psychiatric and general), the relationship with the primary support group (closest family), the relationship with the secondary support group (friends and others) and social occupation (schooling, work, religiosity, and others).(6, 7)

-Objective:
Our goal is to develop an online questionnaire to survey the prevalence of suicidal behavior.

-Method:
The study was approved by the FAMEMA Research Ethics Committee with the number: CAAE: 40205820.0.0000.5413. An informed consent form was developed.
Sample size calculation was based on confirmatory factor analysis. A number of 5 to 10 observations has been stipulated for each variable analyzed. The questionnaire was created with 51 variables. Thus, a sample of 255 to 510 observations was needed.
The questionnaire went through a long process of theorizing. Then, the variables were structured in the proper order. Data collection was done by online convenience sampling to avoid contact during these pandemic times.
The questionnaire went through all stages of validity and reliability. Validation was performed using face validity, content validity, and construct validity. Reliability was performed by test-rest.

-Theorization:
As the first result of our research, we started to describe the foundation work for the development of our questionnaire, which, as will be seen, considering all facets of the theme from a historical rescue with its cultural, philosophical, psychological, sociological, medical, and other. We refer here to the main points that led us to reach an understanding of the issues necessary for our instrument. (8) The earliest historical records of mankind report suicides. (9) The Old Testament records several suicides of Jews, of which we can cite the description in the First Book of Samuel, chapter 31, verse 4-6: "Saul said to his armor-bearer, 'Draw your sword and run me through, or these uncircumcised fellows will come and run me through and abuse me.' But his armor-bearer was terrified and would not do it; so Saul took his own sword and fell on it. When the armor-bearer saw that Saul was dead, he too fell on his sword and died with him. So Saul and his three sons and his armor-bearer and all his men died together that same day."(10) The non-acceptance of a defeat is an important item to be investigated in the social context and will be contextualized within some "CHAPTER 17. OF SUICIDE COMMITTED THROUGH FEAR OF PUNISHMENT OR DISHONOR: And consequently, even if some of these virgins killed themselves to avoid such disgrace, who that has any human feeling would refuse to forgive them.?
And as for those who would not put an end to their lives, lest they might seem to escape the crime of another by a sin of their own, he who lays this to their charge as a great wickedness is himself not guiltless of the fault of folly. For if it is not, lawful to take the law into our own hands, and slay even a guilty person, whose death no public sentence has warranted, then certainly he who kills himself is a homicide, and so much the guiltier of his own death, as he was more innocent of that offense for which he doomed himself to die. Do we justly execrate the deed of Judas, and does truth itself pronounce that by hanging himself he rather aggravated than expiated the guilt of that most iniquitous betrayal, since, by despairing of God's mercy in his sorrow that wrought death, he left to himself no place for a healing penitence? How much more ought he to abstain from laying violent hands on himself who has done nothing worthy of such a punishment! For Judas, when he killed himself, killed a wicked man; but he passed from this life chargeable not only with the death of Christ, but with his own: for though he killed himself on account of his crime, his killing himself was another crime. Why, then, should a man who has done no ill do ill to himself, and by killing himself kill the innocent to escape another's guilty act, and perpetrate upon himself a sin of his own, that the sin of another may not be perpetrated on him?"(12) The proximity of the suicide theme with religion since this time is already perceived, leading us to ask questions about this subject (numbers 21 and 22).
Dante, in describing the immortality of the human soul after death in 1472, exerted such cultural influence that he changed the language of the Italian peninsula from Latin to the dialect spoken by the people of Florence, now known as Italian. (13) The description of suicides in Hell triggered horrors: condensed form, that our state is so wretched that complete non-existence would be decidedly preferable to it. If suicide actually offered us this, so that the alternative 'to be or not to belay before us in the full sense of the words, it could be chosen unconditionally as a highly desirable termination ('a consummation devoutly to be wish'd'). There is something in us, however, which tells us that this is not so, that this is not the end of things, that death is not an absolute annihilation. away with the individual phenomenon, differs most widely from the denial of the willto-live, which is the only act of its freedom to appear in the phenomenon, and hence, as Asmus calls it, the transcendental change. The denial of the will has now been adequately discussed within the limits of our method of consideration. Far from being denial of the will, suicide is a phenomenon of the will's Strong affirmation. For denial has its essential nature in the fact that the pleasures of life, not its sorrows, are shunned. The suicide wills life, and is dissatisfied merely with the conditions on which it has come to him. […] Thus the will-to-live appears just as much in this suicide (Shiva) as in the ease and comfort of self-preservation (Vishnu), and the sensual pleasure of procreation (Brahma). This is the inner meaning of the unity of the Trimurti which every human being entirely is, although in time it raises now one, now another of its three heads. As the individual thing is related to the Idea, so is suicide to the denial of the will. The suicide denies merely the individual, not the species. [...] Suffering approaches and, as such, offers the possibility of a denial of the will; but he rejects it by destroying the will's phenomenon, the body, so that the will may remain unbroken. This is the reason why almost all ethical systems, philosophical as well as religious, condemn suicide, though they themselves cannot state anything but strange and sophistical arguments for so doing." (16) Schopenhauer's words make clear the complexity of the suicide theme by opening the unconscious universe and inviting human spirituality to the discussion. In The power of suggestion and symbology are worked out over the next few decades by the schools in Vienna and Zurich. (29) We believe it is important to use a question with symbols (question 21), inserted towards the end of the questionnaire, to suggest hope for those more "believing" people so that talking about the topic, which is even known not to be associated with risk, can be neutralized. (30) This question will be used to assess how much the power of belief may be more or less correlated with the risk of suicide. They will be quantified in images marked from 1 to 12. Questions of a demographic descriptive nature are included to establish possible correlations with the risk of suicide, such as level of education, occupational status, and sexual orientation (questions 6, 7, 8, and 11). We believe that it is not useful to include a question about race or skin color due to great uncertainty with the answers collected.
Shneidman recalls the importance of the Greek term "Aristos" to define the need to alleviate suffering by seeking the best option.(7) Suicide, due to severe psychic pain caused by a problem, does not see a better solution than suicide. All questions aim to elucidate this relationship.
With the advance of neurobiological knowledge, many studies have sought to demonstrate the correlation between alterations in neuronal circuits and suicide. (37) Although a causal implication between these findings cannot be affirmed, as they can all be part of a broad diseased process of affective and cognitive disorders, dysfunctions in the serotoninergic, noradrenergic and glutamatergic systems are known to be present among suicidal individuals. (38) In the questionnaire, this evidence is considered in the questions of comorbidities.

-Structuring:
The language used in the questions was Portuguese. To have an adequate Questions that directly address the topic of suicide should take the lead in the instrument. They are formulated from a no-risk level to a higher risk. The question: "Você já conversou com algum sobre suicídio?" 2 should take the first position. But we believe it is better to invert its position to the latter to demystify the popular common sense that one cannot talk about suicide and have the effect of deconstructing negative beliefs with the application of the questionnaire in people more vulnerable to suggestion, although there is no unfavorable evidence in this regard. We take the question about psychiatric treatment to the first question. Questions two and three address the topic of suicide with its derivations in an increasing degree of severity as proposed.
In the middle part of the questionnaire, all items on comorbidities, education, and primary support group were inserted. The secondary support group approach and religiosity are inserted in the final stage of the questionnaire with the same objective of leaving a message of hope for those more suggestible people. The main constructs are listed in Figure 2. Although there were other constructs besides suicide in the questionnaire, it takes the "fragmented" form, since the other variables assume a unitary character of evaluation, not being considered in this instrument for prevalence studies their abstractions together.

-Face Validity:
The questionnaire was applied to 10 patients in the office of one of the researchers. All answered the questionnaire in less than 15 minutes. None of them needed help to fill in and all answers were consistent with the questions.

-Content Validity:
The questionnaire was evaluated by two psychiatrists who have been working with suicidal people for over ten years. One of them showed an agreement of 86.9% and the other of 95.6%. No questions or comments were made regarding the content of the disagreed questions. They only made suggestions in the formulation of the questions. In our understanding, the simplicity of some formulations is important to reach a large audience and not need the researcher's help to guide and clarify the answers. Therefore, we rejected the suggestions and accepted the agreement percentage of 91.3%.

-Construct Validation:
A sample of 497 observations from the population group was used. Bartlett's Sphericity Test rejected the null hypothesis that the variables have a correlation of zero and the Kaiser-Meyer-Olkin measure was 0.86. Exploratory factor analysis was performed with all 51 variables using the principal component analysis method with rotation by oblimin with a selection of components with an eigenvalue greater than or equal to 1. 17 factors were extracted (graph 1). The same analysis was performed using the maximum likelihood method with varimax rotation, also extracting 17 factors.
Varimax rotation converged for 13 interactions, where the first factor brings together the variables of personal identification and the second the variables related to suicide.
We emphasize that the two main factors are identical to the oblimin rotation in reverse order (Table 1).
Graphic 1 -17 components with an eigenvalue greater than or equal to 1

-Reliability:
The online questionnaire was applied for 15 days, and 509 observations were obtained. We identified 11 people who answered the questionnaire twice. Of these, 10 responded identically and one of them was disregarded. One person answered the questionnaire differently and both answers were excluded. Of the remaining 497, the first 298 were considered the test, and the last 297 the retest. The test-retest demonstrated an intraclass correlation coefficient of 0.98.

-Discussion:
Applying science in these pandemic times requires adaptations to the new normal.
The development of an instrument for collecting population data needs to consider the need for social distancing. Given the growing need to study suicidal behavior in Brazil, the proposal for a new questionnaire that fits into this current context comes with profound relevance.
The most important step for the development of a work tool is the theoretical foundation. Without neglecting the important role of practical experience, it is known that an experienced bricklayer will find it easier to think about which anvil is best for his craft. Those who work directly with suicides when they come to bibliographic searches are clear about the breadth of the topic.
Suicide confronts health professionals with a vast amount of transdisciplinary knowledge. Only with the humility of an eternal apprentice is it possible to go to philosophy, sociology, theology, and other human sciences to understand the man who gives up on life. It was in this spirit that the team, over the course of a year, dedicated itself to many studies.
After a broad theoretical explanation, the structure considered the times of social isolation and the safety of applying the questionnaire through social networks. It was very important to understand the dynamics of the internet and virtual users. It is known that these pandemic times have required healthcare professionals to experience unprecedented online immersion. In Brazil, telemedicine was authorized. Research in the medical sciences is needed to follow this path.
Although we have used all validation protocols, it is recognized that construct validity is the gold standard. Evaluating a construct is not a passive procedure. On the contrary, it requires in-depth knowledge of the topic and the purpose of the instrument.
Confirmatory factor analysis needs to be accompanied by observation intervals in which the language of numbers needs to be deciphered. After each reading, new analyzes need to be done. Fortunately, we now have powerful software to perform the calculations. Otherwise, this entire process would require more than a year.
Test-retest is often used in procedures to assess reliability. In some situations, it is advised to give a two-week interval between the test to the retest to remove the respondents' recall bias. We understand that this interval was not necessary for this virtual questionnaire understudy, as we were not working with the same respondents in the test and in the retest.
With a great deal of theorizing work that considered all aspects of the suicidal syndrome, the statistical validation analyzes presented no major difficulties along the way. The questionnaire proved to be a reliable tool for suicide prevalence studies.

-Acknowledgments:
We express our sincere gratitude to CAPES for providing bibliographic materials.