Texto & Contexto Enfermagem

Objective: to perform the content validation of the Nurses Global Assessment of Suicide Risk index for the Brazilian population served in primary care. Method: a methodological study of cultural adaptation and content evaluation of the NGASR index, original scale from the United Kingdom, carried out through the stages: evaluation of verbal comprehension by an experts committee (semantic, idiomatic, conceptual and cultural equivalence and content validity), backtranslation and verification of clarity by means of a pre-test. The experts committee was composed of nine judges and the pre-test with 30 users of primary care services and 19 nurses. The Content Validation Index was calculated. Results: the final validated version is composed of 15 items that obtained a Content Validation Index greater than 0.78 by the experts committee and in the application of the pre-test with users and nurses. Conclusion: the instrument favors the performance of professional nurses in primary health care in the prevention of suicidal behavior by facilitating risk assessment and the adoption of relevant actions. DESCRIPTORS: Suicide. Nursing. Primary health care. Validation studies. Risk assessment. Mental health.


3/14 INTRODUCTION
According to the World Health Organization (WHO), suicide is the 15 th leading cause of mortality in the general population and the second among young people aged 15 to 29; it accounts for 50% of all the violent deaths in men and for 71% in women, most commonly in low-and middle-income countries where health resources and services are scarce. 1he epidemiological profile in Brazil presented by the Brazilian epidemiological bulletin, from 2011 to 2016, shows that 48,204 cases of attempted suicide were reported and that there were 55,649 deaths from 2011 to 2015, being considered the third cause of death in males and the eighth among women. 2his panorama, while revealing the magnitude and intensity of suicidal behavior in epidemiological terms, points to the necessary (re)organization of the health care services for the adoption of appropriate strategies for prevention and intervention.Contextually, in terms of locus of care and actions to be developed, Primary Health Care (PHC) becomes a priority.
When examining the scientific literature, some studies indicate high percentages of search for primary care services by individuals with suicidal behavior.One of these, carried out in Scotland, shows that 18.6% of the people dying from suicide had access to mental health services, while 46.4% had contact with primary health care services. 3] Therefore, there is a need for actions to assess the risk of suicidal behavior in primary health care, given that the frequent contact and the relation of the individuals with these services become an opportunity to detect this risk as an initial action for the proper management of cases and to enable the intervention by a multi-professional team. 6The WHO points to the need for comprehensive multi-sectoral strategies for the prevention of suicide, in which community-level approaches must be employed as part of an effective, relatively economical and therefore attractive strategy for low-and middle-income countries, where stigma and taboo often limit quality access to services that promote care for suicidal behavior. 7herefore, in the PHC routine recommended by the Brazilian Ministry of Health, 8-9 there are no instruments for assessing the risk of suicide, especially for application by nurses who are continuously in contact with people who seek the services or who are visited by them.There is a need for strategies for detecting and identifying suicidal behavior at the community level and training the professionals to offer appropriate actions, which allow welcoming, risk assessment, clinical conduct according to the identified risk and monitoring of cases within a Singular Therapeutic Project. 6]

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Therefore, validating the NGASR index for its use by nurses as an instrument for assessing the risk of suicidal behavior in the Brazilian population in primary care services will assist in the effective development of preventive actions that have an impact on the reduction of the suicidal behavior rates.Such focus is in line with a recent Brazilian ministerial decree that instituted the National Policy for the Prevention of Self-mutilation and Suicide, which has among its objectives the development and improvement of methods for collecting and analyzing data on self-harm, suicide attempts and consummated suicides; as well as promoting permanent education for managers and health professionals at all care levels regarding psychological distress and self-harm. 9n view of the above, this study aimed to carry out the cultural adaptation and content validation stage of the Nurses Global Assessment of Suicide Risk (NGASR) index for its use by professional nurses in the Brazilian primary health care services.

METHOD
A methodological study of adaptation and validation of the Nurses Global Assessment of Suicide Risk (NGASR) instrument.It is a simple score index, consisting of 15 items designed so that all the information necessary to score each of the predictive variables can be collected during the Nursing interview. 10he indicator variables are the following: feelings of hopelessness, stressful life events, evidence of hallucinations/persecutory delusions, presence of depressive symptoms, evidence of social withdrawal, warning of suicidal intent, evidence of a suicidal plan, family history of serious psychiatric problems and/or suicide, recent bereavement or loss of a relationship, history of psychotic symptoms, widowhood, previous suicide attempt, history of socioeconomic deprivation, history of alcohol use and/ or abuse, presence of terminal illness.The choice of these variables was based on diverse clinical evidence pointed out in the literature, which highlighted correlations with suicidal behavior. 10n five variables (hopelessness, depressive symptoms, suicidal plan, grieving process, and history of previous suicide attempt), a score of three was attributed, considered a strong statistical correlation with a high degree of suicide risk; the other variables were assigned a score of one.This is a simple scoring index, in which, when the nurse evaluates the presence of the predictive variable, the score of the item is included in the sum.The sum allows for the classification of four suicide risk levels according to the score: low risk (<= 5), intermediate risk (6-8), high risk (9-11), and very high risk (=> 12). 10 In the original version, only face and content validation were evaluated, achieving good results, in addition to verification of use in the clinical practice. 10Only in later studies, such as those carried out in Italy and Portugal, 11,15 it was sought to evaluate the reliability and validity of the criterion and construct of the NGASR index, which found, respectively, Cronbach's alpha values of 0.66 and 0.49, in addition to a linear association with the Beck Scale Ideation scales in the Italian study (R=0.980)and with the Beck Depression Inventory in Portugal (R=0.750), which indicated the instrument as with reliability and with valid and adequate psychometric properties.
To start the validation process, authorization from the authors of the original version was obtained. 10The authors also agreed with the version validated in Portugal, to use it as the initial version in the validation process in the Brazil. 11The authors of the original version were informed on the use of the Portuguese version as the initial version for the validation process for the Brazilian population.
Based on the fact that the Brazilian Portuguese language has linguistic and semantic similarities with that of Portugal, only the following stages of cultural adaptation and content validation were carried out: evaluation by the experts committee of the semantic, idiomatic, cultural and conceptual 5/14 equivalences; content validation, back-translation and verification of understanding, clarity and calculation of CVI through a pre-test, 16 performed from October 2018 to January 2019, as shown in Figure 1.The survey of specialists (judges) was carried out by consulting the lattes curriculum (via the Lattes-CNPq Platform), using the keywords suicide, suicidology, mental health in primary care, psychometry and instrument validation.The selection for the composition of the committee was carried out through the evaluation of academic degrees, professional experience and scientific publication in the area, with a minimum score of 5 points.Twenty-one specialists were contacted via e-mail, when an explanatory letter was sent about the objective of the study, description of the instrument and the concepts involved, information about the context that was intended to be validated and the population involved, with a time limit of 15 days to answer regarding acceptance to participate in the study.
The experts committee was then composed of nine experts in the areas of suicidology, mental health in primary care and methodological studies, to whom a questionnaire was sent to analyze the items regarding simplicity, clarity, relevance, precision and amplitude, with values from 1 to 4 points per item on a Likert-type scale where: 1 = not relevant or not representative, 2 = the item needs major review to be representative, 3 = the item needs minor review to be representative, 4 = relevant or representative item.The questionnaire also contained a space for suggestions on the item's writing; inclusion/exclusion of items.
The committee evaluated the NGASR index at two moments: first with the Portuguese version (initial version in this validation process) in which semantic, idiomatic, cultural and conceptual equivalences were sought, in addition to CVI calculation; at the 2 nd moment, they evaluated the 1 st Brazilian version, composed of suggestions from the first evaluation moment, with a new CVI calculation, resulting in the 2 nd Brazilian version.

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The questionnaire allowed for qualitative and quantitative assessments.The qualitative assessment covered suggestions/changes made by the experts committee.In the quantitative assessment, the Content Validity Index (CVI), global and per item, was calculated by adding up the agreement of the items that received scores with values equal to or greater than 3.The number of answers with a score of 3 or 4 was calculated, divided by the total number of answers.A score above 0.78 was considered adequate, as recommended by authors for studies using six or more specialists. 17tems with a CVI below the stipulated value were reviewed and/or replaced/eliminated.
After changes suggested by the experts committee (exclusion/inclusion of predictive variables, new words written in predictive variables, and change in the scale score), a back-translation of the validated Brazilian version into English was performed by two native translators 16 and sent to the authors of the instrument for acquiescence of the final version.There was no need to back-translate to the Portuguese language of Portugal due to the semantic and linguistic similarities with the Brazilian language, but the version was also sent to the Portuguese authors for their consent.
After this stage, a pre-test was applied to assess the understanding of the meaning of the questions and adequate answer to the instrument, 18 by a single applicator in an exclusive room, in two groups: 30 adult individuals, users of Basic Health Units (BHUs) and 19 nurses who work in these BHUs.The option to carry out this stage of assessing understanding by those who must apply the instrument (nurses), in addition to those who will answer it in the clinical practice (users), was made necessary by the fact that theme of suicidal behavior addressed in the instrument is seen as a gap in the training of professional nurses. 19he sampling of users was for convenience (those who were present in the BHUs were approached, and consent was requested for participation in the study).The pre-test was carried out with all the nurses who worked in the BHUs chosen for the study.A specific Likert-type questionnaire was applied to assess the comprehension of each item, with the following scores: 1 -did not understand the item; 2 -to understand the item it was necessary to repeat at least 2 times; 3 -had no difficulty in understanding the item.The application time of the instrument in each participant was calculated and CVI calculation was performed (with the sum of answers with a score equal to 3, divided by the total of answers) for the two groups of the pre-test application.
The participants were invited and informed about the objectives of the study and, when they agreed to participate, they signed a Free and Informed Consent Form.

RESULTS
The instrument was analyzed, in the Portuguese version, by the experts committee at two moments.At the first moment, the committee made the following suggestions: changes in the writing of the content of items 1,4, 9 and 11 of the Portuguese version; associating item 10 with item 3 and item 13 with item 2; inclusion of two predictive variables, history of interpersonal violence and history of prejudice, in items 10 and 13, respectively; insertion of the term outras drogas (other drugs) in item 14 and, in item 15, of the term incapacitante (incapacitating); and changing the score of item 6 from 1 to 2 points.The second moment consisted of reorganizing and returning the instrument to the committee with the suggested changes.After a new analysis, they agreed and considered it as the final version (Chart 1).During the process of analysis by the experts committee, there was also an evaluation of the items regarding the criteria of simplicity, clarity, relevance and precision, in terms of punctuation.In the Portuguese version, items 10 and 13 presented CVI values between 0.5 and 0.75 in all the criteria.With the adjustments suggested by the committee, all the items in the final version adapted for the Brazilian population reached CVI values equal to or greater than 0.78, in the second stage of evaluation by the experts committee (Table 1).The pre-test included 30 users and 19 nurses, aged between 20 and 59 years old.The mean application time of the NGASR index in the pre-test phase was 12 minutes, considered satisfactory when considering the theme evaluated: risk of suicidal behavior.The content validity index was also calculated in the pre-test stage of understanding of the items by users and Nursing professionals.Table 2 shows that all the items obtained CVI values greater than 0.78 in both groups, which demonstrates good understanding of the instrument.

DISCUSSION
The validation of the NGASR for the Brazilian population resulted in a version composed of 15 predictive variables.The modifications suggested by the experts committee in the writing of some items brought an advance for their better understanding, when observing the CVI achieved in the Portuguese and Brazilian versions.
In item 1, the addition of examples that can reveal the presence of hopelessness, brought more clarity to the identification of the risk of suicidal behavior, this item being one of the most relevant due to the score attributed to it (3).1][22] Hopelessness constitutes a cognitive distortion characterized by the perception of the absence of personal control over future events and by the subjects' expectation that they will fail or face negative consequences in the future. 23n item 4, it was decided to use the term sintomas depressivos (depressive symptoms) instead of depressão (depression) for understanding that a diagnosis is not made at the time of the risk assessment, but it seeks to show symptoms that may indicate the presence of the disorder.This item is also considered relevant because it has a score of 3. Individuals with depressive symptoms are more likely to have a positive screening for suicidal behavior, as pointed out in a study carried out in primary care in Chile, in which 69.9% of the sample referred to a previous depressive condition and 27.7% were under current treatment for depression.Of these, 9.38% were at moderate risk and 30.08% were at high risk for suicidal behavior. 24he idea that grief or the end of a relationship does not necessarily accompany suffering, as it is a subjective experience, but rather the presence of suffering due to loss is what would be the factor related to suicidal behavior.With this understanding, the committee understood that not only did the loss itself support the change in the expression of item 9 from processo de luto recente (recent grieving process) to presença de sofrimento por perda de ente querido (processo de luto recente) ou fim de relação (presence of suffering due to loss of loved one (recent grieving process) or end of a relationship).Grief or ending a love affair is the response to the breaking of a significant bond, and can follow a process of understanding and accepting the loss.The presence of suffering in this process arises when the person begins to experience a prolonged disorganization that prevents them from resuming their previous activities, being considered as factors that trigger suicidal behavior. 25nother modification was the association of item 10 to item 3 of the Portuguese version, due to the understanding that it was content that brought the same construct related to the presence/ history of psychotic symptoms.In addition, item 10 of the Portuguese version, according to the experts committee, presented a CVI below 0.78 in all the analyzed criteria, which indicated the need for change or exclusion for the Brazilian version.Isolated psychotic experiences, such as hallucinations and delusions, as well as schizophrenia, are important markers for suicide risk.] There was also the inclusion of the term dificuldades socioeconômicas (socioeconomic difficulties), which appeared in item 13 of the Portuguese instrument, to item 2 of the Brazilian version.This inclusion is justified by the experts' understanding that it was already implicitly contained in item 2 and also for having obtained a CVI value below 0.78.Issues such as job loss, debt, and financial crisis indicate the presence of destabilizing experiences, which can trigger a suicide attempt for people who have suicidal ideation. 28n order to respect the number of items in the Portuguese instrument, the predictors História de violências interpessoais (físico, psicológico, sexual) (History of interpersonal violence [physical, 10/14 psychological, sexual]), which occupied the position of item 10, and História de preconceito (questões étnicas/sexuais/sociais) (History of prejudice [ethnic/sexual/social issues]), to item 13, were included in the Brazilian version, both with CVI values above 0.78 in all the criteria in the evaluation of the Brazilian version.][30] The inclusion of a history of prejudice related to sexual issues was based on the understanding that sexual option is considered a suicide risk factor.Individuals with a history of same-sex relationships are 3 to 4 times more at risk for suicidal behavior. 31Suicidal behavior in sexual minorities is related, in addition to the common stressors, to other specific stressful factors such as perceived stigma (negative opinions by the majority culture) and self-stigma. 32fter a suggestion by the experts committee, the term outras drogas (other drugs) was added to item 14.This inclusion was not only due to the term use/abuse of alcohol, but also of other drugs, such as illicit drugs, being an important factor for the risk of suicidal behavior in the Brazilian context.In the state of Rio Grande do Sul, in a study carried out in a Psychosocial Care Center, it was demonstrated that abuse of alcohol and other drugs was associated with hopelessness, as well as weakened family relationships, as a result of dependence, conditions that contributed to the suicidal action. 33n the validated Brazilian version, the term incapacitante (incapacitating) was also included in item 15, proposed by the experts committee, justified by the presence of physical diseases with impaired ability to perform daily activities.This condition also has an important relationship with suicidal behavior, as already verified in a study carried out in the United States, which points out some physical health conditions associated with suicide: traumatic brain injury, chronic back pain, HIV/ AIDS, sleep disorders, epilepsy, cancer, migraine, congestive heart failure, and chronic obstructive pulmonary disease. 34here was also a change in the writing and punctuation of item 6, which became more relevant with 2 points in the Brazilian version.For the specialists, the term intenção (intent) would indicate the desire to commit suicide while the added term ideação (ideation) signals the presence of death thoughts.] In the process of validating the instrument with users and professional nurses, it was verified that the application had a time considered satisfactory (a mean of 12 minutes) and was easy to understand, presenting no doubts at the time of application.It is noteworthy that, in the context of primary health care, whose demand for care is considered high, the time to complete the instrument must not be considered an obstacle in its use, in view of being a gateway to the health care networks and the first contact of the suicidal person with the health system.The adequacy of the users' answers and the nurses' understanding of the application of the instruments provides evidence that the NGASR index can be used as an initial and assessment/follow-up instrument in the construction of the care protocol for suicidal behavior involving primary care services, including electronic health records, as in the e-SUS system already adopted in Brazil as a model of electronic medical records.
The limitation presented in this study refers to the content validation stage as an initial moment of analysis of the representativeness or adequacy of the instrument items and, therefore, so that it can be used by nurses working in primary health care, it is necessary to conclude the validation process, analyzing all the metric properties of such a measuring instrument in a large sample, a stage in progress.

CONCLUSION
In the process of cultural adaptation and content validation of the Brazilian version of the NGASR index, the methodology was strictly followed, seeking to ensure the reliability and applicability of the adapted instrument.The final version had 15 items, with a CVI above 0.78 in the evaluation by the experts committee and in the pre-test applied to users and professional nurses, which demonstrates recommended validity results.
The instrument makes it possible to assess the risk of suicidal behavior by professional nurses in primary health care during the Nursing consultation, which gives it the characteristic of practical use, and can even be inserted in electronic medical records as an anamnesis instrument.The nurse, as a professional present in different care contexts, appearing in many of them as a reference person within the health team, when appropriating this tool, in addition to contributing to the qualification of care for people at risk of suicidal behavior by means of a more comprehensive approach, provides greater visibility for the professional practice.For its application, it is also necessary to comply with the other validation stages.

Figure 1 -
Figure 1 -Graphical representation of the stages of the study of adaptation and validation of the NGASR index for the Brazilian population served in primary health care.Teresina-PI, Brazil.2020.

7/14 Chart 1 -
Nurses Global Assessment of Suicide Risk in its version adapted for the Portuguese population and final version for the Brazilian population.Teresina, Piauí, Brazil.2019.

Table 1 -
Content Validity Index (CVI) regarding simplicity, clarity, relevance and precision in the Portuguese version and in the final version adapted for the Brazilian population.Teresina, Piauí, Brazil.2019.(n=?)

Table 2 -
Content Validity Index (CVI) of the understanding of items by users and nurses from the Basic Health Units in the pre-test.Teresina, Piauí, Brazil.2019.(n=?)