Urdu Translation and Validation of Beck Suicide Intent Scale Among Patients with Self-Harming Behavior

Received 01 Aug, 2022

Accepted 01 Sep, 2022

Published 31 Dec, 2022

Literature emphasizes that there is an increasing need to assess underlying suicide intent among patients with self-harm. Since, Beck Suicide Intent Scale (Beck, 1991) is most frequently used instrument to assess underlying suicide intent in clinical setting, the aim of present research was to translate Beck Suicide Intent Scale into Urdu, to examine cross-cultural validation and estimate reliability of Urdu translated scale; a cross-sectional research design was used. A clinical sample of forty patients with self-harm with age of 18 to 35 years was collected from different mental health departments of hospitals in Rawalpindi, Multan and Jehlum, Pakistan. Study was conducted in two phases; in phase I Urdu translation of Beck Suicide Intent Scale was carried out using guidelines by Brislin (1970). In phase II, cross-language validation was conducted through test-retest Cronbach alpha reliability estimation and item-total correlations. Results of current research revealed that Urdu-Urdu group had high correlation coefficients than English-English with acceptable Cronbach alpha reliabilities were adequate. Moreover, significant positive item correlation with composite score of Beck Suicide Intent Scale was found. The findings of current research established that Urdu-version of Beck Suicide Intent scale was reliable and valid for use in Pakistani culture.

The manifestation of self-harming behaviors is on the rise around the globe. Understanding the phenomenon in which an individual deliberately chooses to harm his or her own life in order to get escape from agonizing pain of life or lose a desire to live has perplexed researchers or clinicians for times (Chan et al., 2018). Suicide intent is defined as self-harm behavior with an obvious or inferred motive to die (Bridge et al., 2016). It is difficult and challenging to differentiate the underlying goal of self-harm, whether with or without suicidal intent as both behaviors are deliberately self-inflicted and non-accidental (De Leo et al., 2016). The intent denotes to the purpose, aim or goal behind the act of self-harm, suicidal or non-suicidal thus, inscribes it as a challenging area in clinical practice (Tøllefsen et al., 2018). The challenge with identifying intent is that motive which is unknown, hidden intention that is indefinite or uncertain, hypothesized as unstable intent, unclear intent at the time of act or may be ambiguous recollection of the incident (Silverman et al., 2017).  There is a big need to assess underlying suicide intent among patients with self-harm. Since, Beck Suicide Intent Scale is most frequently used instrument to assess underlying suicide intent in clinical setting. The aim of present research was to translate Beck Suicide Intent Scale into Urdu, to examine cross-cultural validation and estimate reliability of translated scale.
Beck Suicide Intent Scale developed by Beck in 1991 designed to measure underlying intent of self-harming behavior. Beck Suicide Intention Scale comprised of 15 items pertaining to theindividual’s protections and views of that act. Every item is measured from zero to two score range with a likely grand score of 30 indicating the severe intent of suicide or a strong wish to die. The sequence of questions is divided into two parts. First eight questions belonged to the circumstances of the act of self-harm (part 1) pertains to protections, preparation or planning, communication, and anticipations concerning medical facility. The last seven items (part 2) are based on the individual’ own reconstruction of thoughts and feelings at the time of the act. Higher score represents higher suicidal intent i.e. 15-19 low intent; 20-28 medium intent 29 and above high intent. The suggested cut-off value of 15 was for differentiating group differences of suicidal intent and non-suicidal intent (Beck, 1991).
The existing literature supports that the Beck Suicide Intent Suicide is a good instrument for the assessment of the degree of suicide intent among patients with self-harm. There have been no reports on the validation of Beck Suicide Intent Scale of Urdu-version with sample of self-harm. This study aimed at translating Beck Suicide Intent Scale into Urdu and validating the Urdu-version of Beck Suicide Intent Scale. Translation and validation of psychological instruments is very important to address cultural variability and to make the scale more indigenous and reliable across cultures (Bassnett, 2011). Thus, current research presented an empirical test of original version of Beck Suicide Intent Scale in a heterogeneous clinical sample of self-harm patients.

Method

The current research used primarily quantitative approach using cross-sectional survey research design. Data was gathered using purposive sampling technique. The data was collected from mental health departments of different hospitals with equal number of men (n = 20) and women (n = 20). Sample size of forty self-harm inpatients was estimated through EpiTools Epidemiological Calculator with 5% level of significance, 95% confidence level, and 4.7% of absolute precision and 74% estimated true proportion. The age of the participants ranged from 18 to 35 years. Formal written consent was collected from the authorities of the concerning mental health departments and written consent was also taken from each participating client with self-harm in research. Authorities and participants were given with all information concerning research necessities and its process.
Self-reported measure of Beck Suicide Intent Scale was selected for translation and validation into Urdu. The objective of research was achieved in two phases. Phase I consisted of selection and translation of scale and phase II presented empirical testing of Beck Suicide Intent Scale on a heterogeneous clinical sample of self-harm patients (N = 40).

Phase I: Translation of Beck Suicide Intent Scale

In phase I, Urdu translation of selected instrument was done; therefore, items of scale could be easily understand and comprehend in Pakistani culture. Beck Suicide Intent Scale was translated after taking permission from original author. For translation purpose, the guidelines of Brislin (1970) were used by following procedure.

Forward Translation

This step comprised of translating Beck Suicide Intent Scale into target language (Urdu) from the source language (English). For this purpose, three bilingual experts who were fluent in reading, writing, and speaking both Urdu and English languages were requested to translate the said scale into Urdu. Two of the bilingual experts had MS in psychology and one expert had MS in English. Initial translation was carried out according to these instructions: (1) translate the manuscript without excluding any item or word, (2) use reasonably simple language, and (3) emphasis on the content similarity; by following these instructions translators separately translated scale. Three translations were later evaluated in committee approach to select the best translation for each scale.

Committee Approach

The committee was comprised of five members; three had their MS degree in psychology and two members were PhD in psychology and had command on both languages. The committee members discussed each item in terms of its length, comprehension and content. The main emphasis was on examining whether these translated items conveyed the same meaning as given in original scales. The most appropriate translation was selected by the agreement of the committee members.

Back Translation

Back translation of Urdu selected items was done into source language (i.e. English). For this purpose, Urdu-version was given to two independent bilinguals who were different from those who translated the scale into Urdu. One expert had PhD in psychology and one expert had PhD in English. They were instructed to translate the items in such a manner that the context remains unchanged. Received English translations were again evaluated by committee approach.

Comparison with Original Scale

All the back translations were evaluated through committee approach in terms of their equivalence with the original items. There was no ambiguity found in the meaning of the original item for scale.

Phase II: Cross Language Validation

After the translation procedure, the next step was checking the internal consistency of the instrument, which was followed in the phase II of the study. This step was carried out for cross-language validation of the translated version of Beck Suicide Intent Scale through test-retest reliabilities for the English (original) to Urdu (translated) version of the instrument on participants of 40 clients with self-harm.

Figure 1
Representation of sample distribution for test-retest reliability (N = 40).

A sample of 40 clients admitted with self-harm with equal number of men (n = 20) and women (n = 20)was approached through convenient sampling from mental health departments of different hospitals.

Procedure

The cross-language validation on clients with self-harm was accomplished. The sample was divided into four equal groups of ten participants each and distributed in English-English, English-Urdu, Urdu-Urdu and Urdu-English conditions of test-retest. The time interval between the test retest was two weeks. In the first tryout two groups comprising of ten participants in each group were given the original English Beck Suicide Intent Scale and two groups comprising 10 participants each were given Urdu-version of inventory with four testing conditions. Their responses were noted on English-version and Urdu-version respectively. In the second tryout after the 14 days interval, the same 40 patients with self-harm were included to make their responses again, however in the retest try out testing condition were reversed with the same instructions. This whole procedure was carried out in order to identify any equivalence or discrepancy issues between the Urdu and English-version of Beck Suicide Intent Scale. Statistical-Package for Social-Sciences (IBM-SPSS Version 23) was used to analyze data by using descriptive statistics to calculate internal consistency of the scales and item-total correlations were computed.

Results

A sample of clients with self-harm (N = 40) was approached from mental health departments of Jhelum and Multan Military hospitals. Sample consisted equal number of males (n = 20; 50%) and females (n = 20; 50%) with mean age of 23.44 years ± 7.6. Reliabilities for the Beck Suicide Intent Scale (Urdu) was examined by test-retest reliability based on its total score of test and retest. Cronbach alpha reliability was also computed for scale. The results obtained are given as:

Table 1

Test-retest Reliabilities and Cronbach Alpha Reliabilities of the Beck Suicide Intent Scale (N=40)

Note. EU = English-Urdu; EE = English-English; UE = Urdu-English; UU = Urdu-Urdu.

Table 1 shows the correlation coefficients of test-retest administrations of Urdu translated scale explaining four testing conditions that is English-English, English-Urdu, Urdu-English and Urdu-Urdu. High correlation coefficients of Urdu-Urdu group than English-English established that as compared to original English-version, the translated Urdu-version was found to have better comprehension. Results revealed that data is fulfilling assumption of parametric testing and have acceptable Cronbach Alpha reliabilities. The good values of Pearson correlation indicated acceptable test and retest reliability (Smelser, 2001) as all are above .70.

Item-Total Correlation

Confirmatory evidence of content validity of Beck Suicide Intent Scale was also acquired through item-to-total correlation of scale. Item-total correlations were calculated (n = 40) to examine the consistency among items with total of its scale.

Table 2

Item-total Correlation of Beck Suicide Intent Scale (N = 40)

**p < .01.

Table 2 indicated the item-total correlations of Beck Suicide Intent Scale depicting significant positive item correlation with composite score of scale. Moreover, correlation coefficients suggested that all items of the scale were significantly related, measuring the same construct and suggested interconnectedness of the items.

Discussion

It was suggested that Urdu translated scale was requirement for clinical population. Thus, this study presented an empirical test of original version of Beck Suicide Intent Scale on a heterogeneous clinical sample of clients with self-harm. The content similarity of the scales was accomplished through different steps of scales’ translation. Various aspects of reliability and validity of scale were evaluated and good internal consistency and good test-retest reliability for the scale Beck Suicide Intent Scale was found. Results of current research established that as compared to original English-version, the translated Urdu-version was found to have better comprehension Moreover, correlation coefficients of Urdu translated scale suggested that all items of the scale were significantly related and measured the same construct. It indicated that translated version into Urdu was valid and suggesting that Urdu-version of scale measures the constructs as same as to the original English-version as designed to measure. Many other researchers (Halepota & Wasif, 2021; Mumford et al., 2019; Qadir et al., 2015) followed the same method used in current research to determine content validity of the scale. This content validation procedure as suggested by Berg (1997) needs no further statistical test as it is the qualitative procedure of assessment for the translated scale. Yet, another confirmatory evidence of content validity of scale was also acquired through item-to-total correlation of scale. Item-total correlation was calculated in order to examine the consistency among items with composite score of scale. Results of item-total correlation showed significant positive correlation of items with composite score of scale, hence suggesting interconnectedness of the items. Anastasi (1997) suggested significant item-total correlations indicate that scales are valid and examine what they intend to measure. Moreover, correlations between responses on the original English and Urdu translated version is an indicator of cross-language validation. It can be observed that scale has significant correlations (.81). In previous research (Ayub, 2008; Pinninti et al., 2022) internal validity of Beck Suicide Intent Scale was reported as adequate. Researchers used Chinese-version of Beck Suicide Intent Scale to measure suicide intent among Chinese sample and found reliable and valid to assess suicide intent (Beck et al., 1988; Zhang & Brown, 2017). The reliability of the measure Beck Suicide Intent Scale in current research was also found to be satisfactory, meeting the requirement of α ≥ .80 for clinical measures. Results of the present research are in line with coefficients α reported in former studies (Chioqueta & Stiles, 2016) ranging from α = .75 to .98.

Limitations and Suggestions

The present study had some limitations that deserve mentioning Urdu translated scales was validated using item-total correlation and test-retest reliabilities. Future researchers can plan further factor analysis and may adapt scale into short form for clinical population. Likewise, instrument of the present research could also be validated on more diverse sample and lager size of sample that would help to surge generalizability of results.

Implications

Current research presents an effort to empirically test the original version of Beck Suicide Intent Scale in a clinical sample of patients with self-harming behavior. Translation of this scale could be instrumental in addressing cultural variability and to make the scale more indigenous and reliable across cultures.

Conclusion

Overall, the results of present study in terms of psychometric properties of scale were quite encouraging and the scale was found to be reliable and internally consistent.

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Received 01 August 2022
Revision received 11 November 2022