Urdu-Language Translation and Validation of the Ask Suicide-Screening Questions (ASQ) Tool: A Focus on Connotation...

Background Suicide is a significant cause of death in the world, and Pakistan, a low- and middle-income country, is no exception. Despite the increasing number of suicides, Pakistan does not have a validated suicide risk screening tool to identify suicide risk in the national language, Urdu, accurately. This study aims to translate and validate the Ask Suicide-Screening Questions (ASQ) tool into Urdu for suicide risk screening in Pakistan. Methodology We conducted this study at the Services Institute of Medical Sciences (SIMS), a large teaching hospital in Lahore, Pakistan, after receiving the approval of the SIMS Institutional Review Board. The study used a cross-sectional instrument validation study design. The inclusion criteria were youth and adults of both sexes aged 15-45 years, with an ability to understand, speak, read, and write in the Urdu language, who had no cognitive or intellectual limitation to consenting, and who were medically stable to participate. Exclusion criteria included any medical, physical, or cognitive unstable condition to consent or participate. We enrolled 300 participants in our convenience sample from the emergency department (ED), inpatient, and outpatient settings. The ASQ and the ASQ Brief Suicide Safety Assessment (BSSA) were translated and back-translated by Urdu language experts and modified to accommodate cultural and linguistic nuances. The clinician-administered BSSA Urdu version was used as a standard criterion to validate the ASQ by comparing the ASQ-Urdu responses vs. BSSA-Urdu responses. RStudio (version 2023.09.1+494) was used for statistical analyses Results The sample had an enrollment rate of 99.7% (300/301). The sample was 52% female (158/300); the mean age was 27.1 years (SD = 9.4), the overall screen-positive rate was 41.7% (125/300), and 9.3% (28/300) of the participants endorsed a past suicide attempt. In our sample, 35.9% (33/92) of outpatients, 32.2% (19/59) of inpatients, and 49.0% (73/149) of ED patients screened positive on the Urdu ASQ. The screen-positive rate was 16.9% (10/59) for participants aged 17 years and younger, 40.7% (35/86) for participants aged 18 to 25 years, and 51.6% (80/155) for participants aged 26 years and older. Compared to the criterion standard clinician-administered assessment, the Urdu ASQ had a sensitivity of 94.2% (95% confidence interval (CI) = 85.8%-98.4%), a specificity of 73.9% (95% CI = 67.7%-79.5%), a negative predictive value of 97.7% (95% CI = 94.2%-99.1%), and a positive predictive value of 52.0% (95% CI = 46.4%-57.6%). Conclusions The Urdu ASQ has strong psychometric properties, allowing healthcare professionals in Pakistan and worldwide with Urdu-speaking diaspora to identify individuals at risk for suicide efficiently. Utilizing cultural contexts in adapted screening tools improves the accuracy of suicide detection by ensuring that the tools are relevant, sensitive, and respectful to the cultural context of the individuals being assessed. High screen-positive rates in our pilot study underscore the need for early detection and intervention of suicide as a major global public health problem.