4.1 Main findings of the study

We aimed to adapt and assess the psychometric properties of LOSS-B and SOSS-B and determine the level of suicide literacy and stigma toward suicide in Bangladesh. We collected data from 529 university students and tested the psychometric properties of the instruments. The mean age of the respondents was 22.61 ± 1.68, and the majority of them were male (51.8%), graduate students (89.9%), unmarried (92.6%), and Muslim (83.7%) (Table 1). The study population is quite similar to the other studies. The primary instrument development study was done among 676 Australian university populations (Batterham et al., 2013a). The Arabic validation was performed among 160 university students (Aldalaykeh et al., 2020). The Turkish validation study was done among 1100 university students (Oztürk et al., 2017). The Chinese validation study was done among 224 university students (Han et al., 2017). Among the students, only 12.1% had a suicidal attempt, 9.6% had a family history of suicide attempts, and 5.6% had a family history of suicide (Table 1). It was reported 11.3% each in the Arabic study (Aldalaykeh et al., 2020), 12.6% (attempt) and 8.5% (family history of suicidal attempt) in Turkey (Oztürk & Akin, 2018), 10.7% in Chinese college students (Li et al., 2014).

The current study revealed a low literacy in suicide as the mean value of the LOSS-B was 4.27, and only 43.3% of the students scored more than 4 (Table 2). The students had extremely low knowledge of depression and suicidality. On the other hand, they had good knowledge regarding the role of mental health professionals and suicide prevention. The mean LOSS score and rate of passing the mean was 5.63 and 55%, respectively, in the Arabic study (Aldalaykeh et al., 2020), 5.83 and 53% in the Chinese study (Han et al., 2017), a bit lower in the Turkish study (36.9%) (Oztürkand & Akin, 2018), and higher in Australian community (>60%) (Batterhamet al., 2013a, 2013b). The existing stigma, criminality as legal status, culture, and lack of attention in educating the general population regarding suicide could be the responsible factors for this low level of literacy (Arafat et al., 2021). This low literacy is supposed to hinder the help-seeking for suicidal behavior in Bangladesh. Universal strategies should be targeted to raise awareness and improve suicide literacy. Additionally, psychoeducation could improve the literacy status (Batterham et al., 2013a, 2013b).

The current study revealed an acceptable KMO (0.83; p = <.0001) as a value >0.5 has been considered as the criteria (Arafat et al., 2016). The internal consistency of the SOSS-B was measured by Cronbach's alpha which was acceptable (>0.70) in the isolation and stigma subscale (Arafat et al., 2016). It was close to an acceptable value for the glorification subscale (0.68) (Table 3). A similar picture was revealed in the Arabic study (stigma, 0.81; isolation, 0.71; and glorification, 0.68) which could be attributed by translating words into another language that may not produce the exact meaning (Aldalaykeh et al., 2020). The Australian study (Batterham et al., 2013a), Chinese study (Han et al., 2017), and Turkish study (Oztürk et al., 2017) revealed acceptable values of internal consistencies

Due to low factor loading (<0.5), of three items (embarrassment, pathetic, and shallow) of stigma subscale we dropped these three items from the analysis, and the final SOSS-B contains 13 items and three subscales, that is, stigma (five items; item 2, 6, 6, 15, and 16), isolation (four items; item 4, 8, 9, and 10), and glorification (four items; item 1, 3, 11, and 14). The same procedure was followed in the Chinese validation study where four items were dropped due to the poor loading in the stigma subscale and cross-loading with the isolation subscale (Han et al., 2017). All other studies, that is, Australia (Batterham et al., 2013a, 2013b), Jordan (Aldalaykeh et al., 2020), China (Han et al., 2017), and Turkey (Oztürk et al., 2017), revealed three subscales. The observation that three items, namely embarrassment, pathetic, and shallow, had low factor loadings may indicate that either these items are not part of the same construct or that they were not clearly understood by respondents. The three factors covered 61.7% (35.3%, 17.3%, and 9.1%) of variance which was 50% (21.69%, 14.35%, and 13.96%) in Arabic validation (Aldalaykeh et al., 2020), about 60% in the primary validation study (28.5%, 18.2%, and 12.7% (Batterham et al., 2013a), and 61% (28.5%, 17.6%, and 15.9%) in another validation in Australia (Batterham et al., 2013b). The three extracted factors are similar to the other validations and cover acceptable proportions of variance.

The isolation subscale had the highest approval rate among the three subscales of SOSS-B, followed by the stigma subscale and glorification had the lowest approval (Table 3). Broadly similar results were noted in the studies conducted in China and Turkey (Han et al., 2017; Oztürket al., 2017; Oztürk & Akin, 2018). These results suggest that students may ascribe suicide to isolation or loneliness more than providing stigmatizing or glorifying explanations. The correlation assessment revealed a similar structure to the Arabic validation (Aldalaykeh et al., 2020). The overall reliability statistics and the correlation revealed a similar structure to the Arabic validation. We postulate that this might be explained by the same religion of Jordan and Bangladesh.

Interestingly, the approval rate for all stigmatization items was higher among Bangladeshi students compared to Australian students (Batterham et al., 2013b). In contrast, the approval rates for the glorification items were similar between cultures. These findings, from a sample of university students, suggest that suicide is stigmatized among the student community in Bangladesh and that there may be a role for targeted stigma reduction efforts, similar to recommendations from the depression stigma literature (Griffiths et al., 2008). Such interventions may focus on reducing stigmatizing attitudes and increase understanding of why suicides occur. Our findings that males had lower suicide literacy while also endorsing higher stigmatizing attitudes to suicide suggest that interventions targeting suicide-related stigma and awareness must focus on this group.

We noticed that the suicide literacy was significantly higher in females, students of medicine, having a family history of suicidal attempts, and a history of student nonfatal attempts, while stigma was also significantly lower among the females and a history of past attempts (Table 5). The results indicate that destigmatization programs or education programs for suicide prevention might have the greatest impact if they are targeted to males and to people in the wider community without direct experience of suicide. Less stigmatization in females and among the students with psychology degrees was revealed in the primary validation study (Batterham et al., 2013a). Although the current undergraduates have a negligible focus on suicide, the clinical and academic environment could be attributable to this less stigmatization among the medicine faculty students. It is noted that there was a significantly higher score in the glorification subscale among the students with past attempts (Table 5). Also, there was a similar high score in glorification among the community people of Australia with suicidal ideation; however, no change was identified in the past attempters (Batterham et al., 2013b). Another study from Australia identified that the presence of suicidal ideation was negatively associated with help-seeking behavior (Calear et al., 2014).

4.2 Implications of study findings

The major implications of this study are threefold, First, it provides preliminary evidence of the reliability and validity of the LOSS and SOSS scales in a different religious and cultural setting. This demonstrates the applicability of these instruments to diverse populations and contexts. Next, it has identified setting specific knowledge gaps in suicide literacy that may be used to inform suicide awareness programs. Finally, data from the study will assist in developing strategies for dealing with stigmatizing attitudes to commit suicide and enhance suicide-related awareness of society. We suggest that the validity of these scales be examined in the community-related samples with different demographic attributes as suicide-related stigma may vary as a function of age and educational attainment (Griffiths et al., 2008).

4.3 What is already known

Suicide is a neglected public mental health problem in Bangladesh where no attempt to determine the suicide literacy and stigma toward suicide was documented.

4.4 What this study adds

This study validated the two vital instruments LOSS-B and SOSS-B into Bangla those could be utilized in several settings in Bangladesh. It also revealed the level of suicide literacy and stigma among the university students of the country.

4.5 Future directions

Appropriate strategies should be designed to improve the literacy of suicide and reduce the stigma in Bangladesh. Future community-based studies assessing the relationship of help-seeking and level of literacy and stigma should be aimed.

4.6 Strengths and limitations

This is the first attempt to test the psychometric properties of the LOSS-B and SOSS-B as well as to determine the level of suicide literacy and stigma in Bangladesh. However, the study has several limitations. First, only internal consistency form of reliability was assessed without determining other forms such as test, retest, and inter-rater. Second, we did not assess the detailed psychometric properties of the LOSS-B as it is an edumetric instead of psychometric tool where there are correct answers rather than opinions/attitudes/behaviors. Third, data were collected from the university students that may restrict the generalization of study results. Fourth, samples were collected conveniently that might be a source of selection and response bias that hinders the generalization of study results.