52 Suicide and Life-Threatening Behavior 33(1) Spring 2003

 2003 The American Association of Suicidology

Development of a Questionnaire on Attitudes

Towards Suicide (ATTS) and Its Application
in a Swedish Population
ELLINOR SALANDER RENBERG, PHD, AND LARS JACOBSSON, MD, PHD

An instrument measuring attitudes toward suicide was developed through

two postal questionnaire surveys, 1986 and 1996, approaching general population
samples of 700 and 1,000 persons, respectively, and with response rates of 75%
and 64%. A 10-factor model was obtained and comparisons between waves re-
vealed an overall more permissive and pro-preventional attitude in 1996. The
results implied complex relationships at the aggregated level between attitudes
and suicidal behavior, depending on type of suicidal behavior, attitude factor, and
subgroup. At the individual level, persons answering affirmative on own suicidal
behavior, as compared to the nonsuicidal group, held a more permissive and un-
derstanding attitude toward suicide.

Suicide and suicidal behavior occur in a social
and cultural context, reflected in the signifi-
cant variations in rates of suicide and attempted
suicide in different countries. These differ-
ences cannot sufficiently be explained by var-
ying living conditions (e.g., unemployment,
divorce rates, alcohol consumption), nor prev-
alence of psychiatric disorders (Neeleman &
Lewis, 1999). Many researchers have dis-
cussed the necessity of more explicit studies
ELLINOR S. RENBERG and LARS JACOB-
SSON are with the Department of Clinical Sci-
ences, Division of Psychiatry and WHO Collabo-
rating Centre, Umeå University, Umeå, Sweden.
This study was supported by grants from
the Swedish Council for Planning and Coordinat-
ing of Research and from the Swedish Council for
Social Research. Special thanks to Birgitta Törnk-
vist, Department of Statistics, Umeå University,
for her statistical expertise.
Address correspondence to Ellinor Salander
Renberg, Department of Clinical Sciences, Divi-
sion of Psychiatry, WHO Collaborating Cen-
tre, Umeå University, SE-901 85 Umeå, Sweden;
E-mail: ellinor.salander.renberg@psychiat.umu.se.
on the normative evaluation of suicide in or-
der to improve our understanding of the
mechanisms influencing suicide and suicidal
behaviors at an aggregated as well as an indi-
vidual level (e.g., Canetto, 1992–93; Diek-
stra, 1989; Farber, 1968; Lester, 1972; Neele-
man & Lewis, 1999; Platt, 1989; Schmidtke,
1997).
A predominant view among research-
ers has been that the more permissive atti-
tudes toward suicide in a specific group, the
higher the suicide rate, and that repressive at-
titudes toward suicide may deter vulnerable
individuals from suicidal behaviors (e.g., Farb-
erow, 1989; Ramsay & Bagley, 1985). Results
from different studies on attitudes toward
suicide, however, demonstrate no unequivo-
cal empirical evidence for such an associa-
tion. In the European Values Study (EVS;
Halman, 1993), comparisons between coun-
tries’ rank order of suicide rates and permis-
sive attitudes toward suicide revealed no as-
sociation. Even changes over time disclosed no
association, and while Sweden experienced a
decrease in suicide rates between 1981 and
RENBERG AND JACOBSSON
1990, the permissiveness had increased. Most
studies on the association between suicide at-
tempt rates and permissive attitudes imply a
negative relationship (e.g., Kerkhof & Nata-
wat, 1989; Platt, 1989; Sale, Williams, Clark,
& Mills, 1975). More hostile and intolerant
attitudes were found in areas with high rates
of attempted suicide as compared to low-rate
areas. However, at an individual level, per-
sons with a history of suicidal behavior held
a more permissive attitude. A general prob-
lem in this matter, first expressed by Gibbs
(1968), is the difficulty in assessing the direc-
tion of the influence (cause-effect sequence);
that is, whether attitudes influence behavior
or if behavior induces attitude changes.
A variety of methods and designs have
been applied to measure attitudes toward sui-
cide, resulting in limited possibilities to com-
pare results from different studies. The meth-
ods have varied from open, semistructured
interviews, often combined with simple se-
mantic differential scales (Osgood, Suci, &
Tannenbaum, 1957), to large-scale surveys
using questionnaires. The attitudes measured
have also varied, from one dimensional atti-
tudes toward suicide (e.g., favorable-unfavor-
able), as was done in the EVS, to comprehen-
sive studies on different attitude components
(Domino, Moore, Westlake, & Gibson, 1982),
also taking into consideration the role of who
the target person is and who the evaluator is
(Deluty, 1988–89; Diekstra & Kerkhof, 1989;
Marks, 1988–89; Stillion, McDowell, & Sham-
blin, 1984). In a recent study by Jenner and
Niesing (2001), an interesting combination
of the semantic differentiated scale method
and different actors is applied; however, the
instrument is limited to measuring only two
dimensions of attitudes towards suicide (health/
illness and acceptance/rejection).
The aim of the present study was to
construct a feasible instrument to measure
attitudes toward suicide in large-scale surveys
in the general population. Some of the goals
were to cover multidimensional aspects of at-
titudes toward suicide, and to describe atti-
tude changes over time, as well as the associ-
ation between attitudes and suicidal behavior.
53
The study constituted part of a suicide pre-
vention project where special interest was di-
rected toward attitudes concerning preven-
tion of suicide.
STUDY AREA
The study area consisted of the county
of Västerbotten in the north of Sweden, with
a total population of about 260,000 (Statistics
Sweden, 1996). A detailed description of the
area, including information on suicide and
parasuicide rates, can be found elsewhere
(Salander Renberg, & Jacobsson, 1999; Sa-
lander Renberg, 1999). The county is as an
appropriate area for conducting epidemio-
logical studies since it includes quite different
human milieus with divergent suicide rates.
The highest suicide rates were found in the
most depopulated rural areas and in the most
expanding urban areas, whereas the lowest
rates were found in the remaining “mixed
areas.”
CONSTRUCTION OF THE
ATTITUDE QUESTIONNAIRE
The questionnaire measuring attitudes
toward suicide (ATTS) was developed and
fielded on two different occasions, with ten
years in between; consequently, the develop-
ment of the questionnaire and data collection
were conducted simultaneously. Both ques-
tionnaire studies were approved by the ethi-
cal committee of the Medical Faculty of Umeå
University. Statistical methods used in the
development of the instrument were factor
analysis using varimax rotation, chi-square
tests and F-tests ( p ≤ .05) for comparisons
between groups; and for internal consistency
Cronbachs alpha was applied.
First Wave
With influence from the Suicide Opin-
ion Questionnaire (SOQ; Domino et al.,
1982), a first version of the ATTS was devel-
54
oped in the middle of the 1980s, using a 5-
point Likert scale (agree completely, agree to a
large extent, doubtful, do not agree and agree not
at all). Several clinicians with a broad experi-
ence in suicidal problems and a group of lay-
men were asked to check the questions in the
pool and give suggestions on new questions.
With the help of their opinions, 80 questions
were chosen for a preliminary version of the
questionnaire, which was piloted in a group
of students (N = 50). After exclusion of items
with extremely low discriminative power
or shortcomings in formulation, 62 attitude
questions remained, covering the three com-
ponent areas instrumental, affective, and cog-
nitive. Included in the questionnaire were
questions on basic demographic data: sex, age
(18–30, 31–50 and 51–65), educational length
(9 and under, 10–13 and 14+ years), cohabit-
ing status, region (urban, rural, and mixed),
and experience of suicide and suicidal prob-
lems among significant others. The question-
naire constituted part of an instrument that
also measured suicidal behaviors, suicide
attempts, plans, ideation, death wishes, and
life-weariness using questions developed by
Paykel, Myers, Lindenthal, and Tanner (1974).
Results from this part have been presented
elsewhere (Salander Renberg, 2001).
Postal questionnaires were distributed
to a randomly selected sample of 710 persons
from the general population, aged 18 to 65
years. The first study was actually conducted
on two different occasions, in spring 1985
and spring 1987, but as there was no differ-
ence between the studies concerning distri-
bution of demographic variables, they were
pooled together and labeled as the 1986 study
(Salander Renberg, 2001). A letter of infor-
mation, in which the study was presented and
a decoding procedure guaranteed, was sent
together with the questionnaire. Two follow-
up letters were sent as reminders to those
who did not respond after 2 and 4 weeks, re-
spectively.
From the original sample a total of 522
persons did answer the questionnaire, and
after excluding 12 subjects from the original
population (e.g., because of language and
learning difficulties, or recent change of resi-
QUESTIONNAIRE ON ATTS
dence) a response rate of 75% was obtained.
Representativity of the answering group was
ascertained by comparing the population, sam-
ple, and answering group concerning sex, age,
cohabiting status, educational length, and resi-
dence, and is presented in detail elsewhere
(Salander Renberg, 2001). The responders
matched well with the population on vari-
ables such as age, educational length, and res-
idence, and also exhibited a response pattern
common in postal surveys: a higher propor-
tion of females (56% vs 49%) and cohabiting
persons (73% vs 63%).
It was not possible to obtain an inter-
pretable factor model by explorative factor
analysis for the original 62 items. Therefore
a reassessment of the included items was per-
formed. The distribution for the obtained
answers was calculated for each item and in
cases of extremely skewed or high kurtosis
(leptokurtic) distribution the items were ex-
cluded from further analysis as they were as-
sumed to have a too low discriminative power;
items with very low correlation with other
items were also excluded. Items were again
scrutinized concerning formulation and re-
analyzed concerning relevance for the aims
of the research project. At this point it was
decided to emphasize and focus on preven-
tive aspects instead of cognitive aspects, lead-
ing to the exclusion of items primarily con-
cerning causes to suicide. An explorative factor
analysis was performed for a remaining num-
ber of 22 items, using varimax rotation, and
after exclusion of two items with low com-
munality (<.40)—that is, the total variance of
a variable accounted for by the combination
of all common factors—an interpretable
eight factor model was obtained including 20
items. The eight factors accounted for 63 %
of the total variance, all with eigenvalues over
1 and each over 5% of the total variance ex-
plained. Items with loadings over ±.40 were
chosen in the interpretation of the factors
shown in Table 1.
Second Wave
Ten years later the research group was
interested in repeating the study as well as
RENBERG AND JACOBSSON 55

TABLE 1
Obtained Factors, Explained Variance, Items (abbreviated), Factor-Loadings
and Internal Consistency for the 20-item Version, 1986
Explained Factor- Internal
Factor Variance Loading Consistency*

1 Permissiveness 13.2% .66

Right to commit suicide .71
Situations where suicide is the only solution .67
Suicide ones own business .64
Suicide acceptable to end an incurable suffering .63
2 Unpredictability 11.5% .60
Suicide happens without warning .78
Relatives have no idea about what is going on .75
3 Incomprehensibility 8.3% .40
Suiciders are mentally ill .73
Suicides among younger people particularily puzzling .63
Anybody can commit suicide −.46
4 Noncommunication 6.9% .65
Communication not serious .80
People who make threats seldom complete suicide .80
5 Right to prevent 6.5% .34
Attempts a cry for help .75
Duty to restrain a suicide act .65
6 Preventability 6.0% .53
Can always help .87
Suicide decision can’t be reversed −.69
7 Relation-caused 5.5% .45
Attempts due to interpersonal conflicts .79
Attempts due to revenge or punishment .72
8 Suicidal process (duration) 5.0% .38
Suicides considered for a long time .80
Attempts are impulsive actions −.67
Suicidal thoughts will never disappear .45
WHOLE INSTRUMENT 63% .51

*Cronbach’s alpha

finding ways to increase reliability and valid-
ity, now with influences from recent studies
in the field of attitudes toward suicide (Diek-
stra & Kerkhof, 1989; Rogers & DeShon,
1995). The first step included a theoretical
definition of attitude areas with regard to the
different referent levels described by Diekstra
and Kerkhof (1989). The original 20 questions
quite well into the model and were kept in
their original formulation to make compari-
sons possible; however, since items often were
formulated on a people in general referent level
they were complemented with formulations
on other referents; that is, for the respondent
him/herself or for a close relative. A total of
69 questions were initially constructed and
after comparison with the results from the
Dutch study (Diekstra & Kerkhof, 1989),
only referent levels that had been found to
be of crucial importance were kept. This sim-
plified the procedure considerably, since
fewer combinations of different referents
were necessary to use, and out of 69 attitude
items 40 were retained.
In the second study, performed in
spring 1996, a likewise randomly selected
56
group of 1,000 persons, between 18 and 65
years of age, was approached. A similar pro-
cedure as in 1986 was applied, and a total
response rate of 64% was obtained. When
comparing the responding group with popu-
lation, there were, as in 1986, differences
concerning gender and cohabiting status. A
confirmatory factor analysis with the restric-
tions of 8 factors was conducted with the
original 20 questions, resulting in a model
explaining 63% if the variance. The obtained
eight factors corresponded very well with the
original factor model (it included the same
questions). When adding the new questions
into the factor analysis, and after exclusion of
items with low loadings (<.40) or low com-
munality (<.40), a ten-factor model was ob-
tained explaining 60% of the total variance
(Table 2). This model included 34 questions.
In this factor model, as compared to
the 20-item model from 1986, items from the
original permissive factor were spread out
into three separate factors: suicide as a right,
tabooing, and resignation. The predictability
and communication factors were combined
into one communication factor, and the in-
comprehensibility factor was divided in two:
incomprehensibility and the normal-common
factor. The internal consistency was high
(>.70) for the two first factors, and had in-
creased for the whole instrument. However,
for some factors, the internal consistency was
rather poor, especially factors 5, 8, and 9.
ATTITUDES TOWARD SUICIDE
IN DIFFERENT GROUPS
For comparisons between the two sur-
veys, the original 20-item version from 1986
was used as the bases. The 1996 34-item model
was used to describe attitudinal differences be-
tween subgroups.
Comparisons between waves
Distribution of responses on the eight
factors from 1986, represented by the item
with the highest factor loading are presented
in Table 3. The five response categories were
QUESTIONNAIRE ON ATTS
collapsed into three categories, reflecting agree-
ment, undecided, and disagreement. Overall
differences between waves were found con-
cerning 4 of 8 selected attitude questions, but
only on the right to commit suicide question
was the attitude change valid for both gen-
ders. Comparisons between genders also re-
vealed a pattern where some differences dis-
appeared (e.g., right to commit suicide) and
some emerged (e.g., possibilities to help a
suicidal person). Age-specific responses on
the different attitude questions (not shown in
the table) revealed that for the right to com-
mit suicide, there were no differences be-
tween age groups, and the higher level of
agreement in 1996 was significant ( p ≤ .05)
for all age groups. Older persons (51–65), of
both genders, agreed to a significantly higher
extent on the sentence that people who com-
mit suicide are mentally ill, but there was a
general decrease in agreement on this item
among all age groups over time. Younger per-
sons (18–35), of both genders, held a stronger
belief than others that it is always possible to
help a suicidal person. In 1996, there was a
significant higher level of agreement on this
item in all age groups, as compared to 1986.
Suicidal communication was considered as
more serious by the youngest age group, in
both waves.
Attitudes Toward Suicide in Different
Demographic Groups
Data from the 1996 survey disclosed in-
teresting patterns concerning attitudes toward
suicide in different groups (Table 4). F-tests
were applied to compare mean factor scores
(regression technique) between the groups. The
factor scores are standardized measures with
an overall mean of 0 and a standard deviation
of ±1.
The youngest as well as noncohabiting
persons held the most permissive attitudes,
however, this was significant only for women.
For men the most permissive attitudes were
found among those living in an urban area.
While no gender differences were disclosed
on the right to commit suicide factor, differ-
ences were found on factors such as non-
RENBERG AND JACOBSSON 57

TABLE 2
Obtained Factors, Explained Variance, Items (abbreviated), Factor-Loadings and Internal Consistency
for the 34-item Version 1996
Explained Factor- Internal
Factor Variance Loading Consistency*

1 Suicide as a right 16.3% .86

Get help to commit suicide if severe, incurable disease–myself .82
Give help to commit suicide if severe, incurable disease–people .78
Suicide understandable if severe, incurable disease–people .78
Consider suicide if severe, incurable disease–myself .76
Suicide acceptable means to end incurable disease–people .72
Right to commit suicide–people .66
Suicide should not always be prevented .43
2 Incomprehensibility 9.9% .72
Suicides among younger people particularily puzzling .70
Suicide among the worst thing to do to relatives .70
Not understandable that people can take their lives .69
Suicide can never be justified .55
Low estimated own suicide probability .41
3 Noncommunication 6.1% .64
Communication not serious .66
People who make threats seldom complete suicide .66
Suicide happens without warning .64
Relatives have no idea about what is going on .64
Most people avoid talking about suicide .46
4 Preventability 5.5% .63
Can always help .82
Suicide can be prevented .68
Suicide decision can’t be reversed −.59
5 Tabooing 4.9% .45
Should or would rather not talk about suicide .74
Risk to evoke suicidal thoughts if asked about .60
Suicide ones own business .41
6 Normal—common 3.8% .51
Could express suicide wish without meaning it—myself .70
Everyone has considered suicide .63
Anybody can commit suicide .46
7 Suicidal process 3.7% .51
Suicides considered for a long time .86
Attempts are impulsive actions −.75
8 Relation—caused 3.5% .45
Attempts due to interpersonal conflicts .77
Attempts due to revenge and punishment .71
9 Preparedness to prevent 3.1% .38
Prepared to help a suicidal person—myself .79
Duty to restrain a suicidal act .57
10 Resignation 3.1% .54
Suicide a relief .70
Situations where suicide is the only solution .44
WHOLE INSTRUMENT 60% .60

*Cronbach’s alpha
 58

TABLE 3
Responses on Eight Single Questions, Each Representing a Factor, 1986 and 1996, in Percent for Women (W)
and Men (M), Respectively
Diff*
Gender 1986–1996
ATTITUDE QUESTION 1986 Gender 1996 Gender spec. Overall
(abbreviated) Gender Agree ? Disagree diff* Agree ? Disagree diff* diff* diff*

Right to commit suicide W 8 17 75 .00066 20 31 49 ns .00000 .00000

M 16 25 59 25 30 45 .00488
Suicide happens without warning W 25 29 46 ns 27 33 40 .03816 ns .03580
M 25 27 49 35 26 40 .03385
Suiciders are mentally ill W 27 27 46 .00611 30 29 42 ns ns ns
M 40 22 38 26 29 45 .00314
Communication not serious W 31 33 37 ns 22 48 30 .00592 .00045 .00029
M 31 41 28 31 48 21 ns
Suicide attempt cry for help W 97 3 3 .02843 94 5 1 .00756 ns ns
M 92 6 2 88 11 1 ns
Can always help W 45 45 9 ns 53 42 6 .02738 ns .00546
M 54 36 11 63 32 6 .03628
Attempts due to interpers conflicts W 26 43 31 ns 32 35 33 ns ns ns
M 24 44 32 29 44 27 ns
Suicides considered for long time W 73 23 4 ns 75 21 4 ns ns ns
M 69 25 6 73 23 4 ns

? = undecided
*chi-square test, p-value
ns = p > .05
QUESTIONNAIRE ON ATTS
RENBERG AND JACOBSSON 59

TABLE 4
Responses on the Right to Commit Suicide Factor in 1996, Gender Specific
Mean Factor Scores in Different Demographic Groups
Women Men
Gender
Factor- Diff* Factor- Diff* Diff*
Demographic Group Score p-Value Score p-Value p-Value

Total −.0118 .0198 ns

Age 18–30 .1134 .0797 ns
31–50 .0267 .0281 .0654 ns ns
51–65 −.2847 −.1056 ns
Region Urban .0920 .2837 ns
Mixed −.1602 ns −.1916 .0037 ns
Rural .1138 −.0048 ns
Education −9 −.1621 .0408 ns
10–14 .0646 ns .0377 ns ns
14+ −.0088 −.0325 ns
Cohabiting Yes −.0888 .0340 −.0331 ns ns
No .1847 .1371 ns
Suicide nearby Yes −.0777 ns −.0123 ns ns
No −.0012 .1817 ns
*F-test
ns = p > .05

communication, tabooing, normal-common ferences were found only on the incomprehen-

and resignation (suicide as a solution), where
men to a higher extent agreed on the state-
ments included. As for other attitudes and
background factors, age-group comparisons
showed least understanding among the oldest
women, while significantly more pro-preven-
tional attitudes and less tabooing were found
among the youngest, both genders. The oldest
men showed, as compared to the younger, the
most resigned attitudes; that is, that suicide
could sometimes be a relief and the only so-
lution. Concerning regional differences, men
in urban areas were the most pro-preventional
men, and women in mixed areas responded
with more resignation toward suicide than did
women in other areas. Concerning educa-
tion, the well educated (14 years or more), of
both genders, were more understanding, did
believe more in communication prior to sui-
cide, and were less tabooing. However, well-
educated men showed a more resigned atti-
tude toward suicide than did men with shorter
education. When comparing gender-specific
attitudes related to cohabitational status, dif-
sibility factor, where non-cohabiting women
were more understanding than the cohabit-
ing. Finally, women reporting on experiences
of a suicide nearby were less agreeing on the
relation-caused factor than other women.
Association to Self-reported
Suicidal Behaviors
Gender-specific comparisons were made
between the group responding affirmative on
any of the questions on suicidal behavior con-
cerning last year (life-weariness, death-wishes,
suicidal ideation, suicidal plans, attempted sui-
cide) and the ’“non-suicidal” group on each
of the 10 factors (Table 5).
Suicidal women were, as compared to
nonsuicidal women, significantly more agree-
ing on suicide as a right, were more under-
standing, considered suicidal behaviors as more
normal-common and more relation-caused.
Suicidal men, as compared to the non-suicidal,
to a larger extent regarded suicidal behavior
as normal and relation-caused.
60 QUESTIONNAIRE ON ATTS

TABLE 5
Mean Factor Scores on the Ten Attitude Factors Obtained in 1996, with Regard
to Self-Reported Suicidal Behavior During Last Year (Yes, No), Gender Specific and Total
Women Men TOTAL
Yes No Diff* Yes No Diff* Yes No Diff*
FACTOR n = 118 n = 229 p-Value n = 95 n = 192 p-Value n = 213 n = 421 p-Value

Suicide as a right .1434 −.0971 .048 .1215 −.0314 ns .1337 −.0703 .024
Incomprehensibility −.3372 .1353 .000 −.0757 .0879 ns .2217 −.1147 .000
Noncommunication −.2915 −.0548 ns .1123 .1815 ns −.1132 .0581 ns
Preventability −.1284 .0015 ns −.0436 .0967 ns −.0910 .0458 ns
Tabooing .0800 −.2259 ns .3063 .1602 ns .0906 −.0454 ns
Normal-common .3718 −.3309 .000 .5317 −.1259 .000 .4424 −.2312 .000
Suicidal Process .1480 .0009 ns −.0316 −.0722 ns .0687 −.0368 ns
Relation-Caused .1592 −.1384 .023 .2139 −.0391 .036 .1834 −.0933 .002
Preparedness
to Prevent .0652 −.0344 ns −.0284 .0068 ns .0238 −.0133 ns
Resignation −.1133 −.1045 ns .2113 .0859 ns .0300 −.0152 ns

*chi-square test
ns = p > .05

DISCUSSION but comparisons based on basic demographic

When designing the study and decid-
ing to use a postal questionnaire approach,
questions were raised on the appropriateness
to do so. Could it even be dangerous since it
might provoke and evoke suicidal problems,
and would people actually respond? The re-
sponse rates of 75% and 64%, respectively,
indicate that people in general actually do
feel great concern for the problem and are
prepared to respond, despite the fact that it
might be frightening and provoke anxiety.
Some people responding to the questionnaire
made comments like: “A very important
study, it was not easy to fill in the question-
naire but the questions are very important
and we must learn to talk about and reflect
on these issues, I hope I have been of some
help.” In this situation, it could even be a
preventive intervention per se to ask the pub-
lic about suicide to increase general aware-
ness and hopefully the preparedness to pre-
vent suicide in society. However, we still have
a situation with nonresponders that should
not be neglected.
The design of the study did not allow
for a study in nonresponders in more detail,
variables did demonstrate a quite satisfactory
representativeness. Furthermore, according
to results from the other section of the ques-
tionnaire on self-reported suicidal behaviors
(Salander Renberg, 2001), the responders did
reveal quite high prevalences of suicidal be-
haviors, indicating that the group of respond-
ers were persons quite familiar with suicidal
problems. If this assumption is correct, the
nonresponders could constitute a group not
that close to or involved with suicidal prob-
lems, and consequently, according to the re-
sponses from the suicidal group, there could
be some bias concerning permissiveness, in-
comprehensibility, normal-common, and re-
lation-caused. Some reasons given from the
nonresponding group, even though just a
few, said that this was a too difficult and hard
problem to approach and that they felt un-
comfortable to answer the questionnaire.
Construction of the Instrument
Beside the question on selection bias,
reliability and validity issues have to be ad-
dressed. Concerning reliability, internal con-
sistency was increased in the second version
RENBERG AND JACOBSSON
of the instrument, especially for some sepa-
rate factors, where probably the new ques-
tions on different referents contributed to
the increase. Still the internal consistency
was low for the whole instrument and on
some factors even very low. Possibly, the in-
strument is measuring a too broad area of at-
titudes toward suicide. An alternative would
be to include more items on each domain and
to cover fewer domains, since internal consis-
tency increases with the number of items on
each factor (e.g., Guilford, 1954). However,
the psychometric properties of the instru-
ment had to be balanced with the ambition
to develop a multi-dimensional as well as fea-
sible instrument for the use in large-scale
studies (not too time consuming and exten-
sive). The internal consistency measure is
probably also influenced by the non clear-cut
nature of the attitudes toward suicide and the
ambivalence associated to the phenomenon.
A crucial issue is whether an instrument mea-
suring different attitude domains really can
yield a high total internal consistency since
different attitudes toward suicide might be
conflicting and instable. Another important
factor influencing the reliability is the heter-
ogenity of the population under study (an in-
evitable condition in this study), beside the
heterogenity of the instrument. The ques-
tionnaire was aimed at measuring different
domains in a very heterogenous group of in-
dividuals, and can, consequently (theoretically),
hardly accomplish the demands of high con-
sistency. Most questionnaire studies conducted
in the field of attitudes toward suicide are
tested and fielded on quite homogenous groups,
such as students. Such samples imply other
conditions for high consistency.
As for the validity aspects, obtaining an
identical factor model in both 1986 and 1996,
based on the 20-item version, is satisfying and
gives support for a high construct validity. By
constructing the questionnaire after consult-
ing several experts in the area as well as asking
laymen it is possible to guarantee a rather high
face validity, and the criterial validity was
partly met by the association with own sui-
cidal behavior. However, it is not obvious to
which behaviors attitudes should be related:
61
suicide or attempted suicide, ideation or pre-
paredness to help persons in suicidal crisis.
In current study the definition of the attitude
target is quite broad, and a strong argument
for including all these targets is that we ac-
tually do not have sufficient knowledge on
whether and how attitudes are differentiated
regarding suicide and other suicidal behaviors.
Most questions concern suicide, but there are
exceptions (factor 6, 7, and 8). In future stud-
ies it might be warranted to more clearly sep-
arate the different attitude targets, in order
to make separate analysis for different tar-
gets.
Associations Between Attitudes
and Suicidal Behavior
Data speak in favor of both positive
and negative associations, depending on atti-
tude, type of suicidal behavior, and subgroup.
A higher level of permissive attitudes in 1996
as compared to 1986, coincided with a con-
tinuous decline in suicide rates in Sweden
since the beginning of the 1980s, suggesting
a negative association, where suicide rates de-
crease and permissiveness increases. Gender-
specific patterns to the contrary supported a
positive association in 1986, where women
who had suicide rates about four times lower
than males, were less permissive. However, in
1996 the female pattern was changed, giving
a situation where gender differences in per-
missiveness disappeared. If permissive atti-
tudes actually lead to a raise in suicide rates,
as was suggested by Farberow (1989), this in-
crease in permissiveness among females might
indicate a forthcoming increase in female sui-
cide rates. There are indications of such a sit-
uation among younger females according to
recent studies where the rates for young wom-
en are not declining in Sweden, as compared
to rates in most other age groups (Hultén,
2000). Another quite surprising finding in the
gender pattern was that men in 1996 to a high-
er extent than women believed in the possi-
bilities to help a suicidal person (single item
comparisons). This might reflect a possible
change in help-seeking behavior among men,
62
contributing to the current decrease in sui-
cide especially among males.
An interesting finding was that the gen-
eral response-style changed toward a more
frequent use of the undecided option on sin-
gle items in 1996. This might reflect the non
clear-cut nature of attitudes toward suicide,
but also a generally increased awareness and
knowledge in society regarding suicidal be-
haviors. Changes in some attitudes were clearly
manifested in that sense (e.g., how to assess
suicidal communication), where almost half
of the respondents, both genders, chose the
undecided alternative in 1996.
Although there were no gender differ-
ences in 1996 concerning permissiveness, such
differences were found on factors that can be
considered as central preventional ones: com-
munication, tabooing, normality, and resig-
nation. These results support the importance
of measuring different attitude areas and not
only unidimensional attitudes.
Since the relative rates of attempted
suicide in different subgroups are nearly the
reverse as compared to suicide rates, the as-
sociation between suicide attempt rates and
attitudes toward suicide are reverse as well.
We find the most permissive attitudes in
groups with the highest rates of attempted
suicide (younger women) (Salander Renberg,
1999). These age- and gender specific pat-
terns are important to consider, not only be-
cause they differ per se but as they probably
can take on different meaning in different
groups.
In correspondence with other studies
(Kerkhof & Natawat, 1989; Platt, 1989; Stein,
Brom, Elizur, & Witztum, 1998), positive as-
sociations at the individual level were found
between permissive attitudes toward suicide
and self-reported suicidal behavior. The fac-
tor includes items on the right to commit sui-
cide if ones suffering becomes unbearable, thus
guaranteeing a way out. A group of suicidal
persons might be close to that experience,
and may psychic pain is too unbearable, that
they have considered or even made an act to
escape from that suffering. It would be inter-
esting to also approach a group of suicide at-
QUESTIONNAIRE ON ATTS
tempters to further investigate this attitude
in a more clinically defined group. For a sui-
cidal person the interaction with the sur-
rounding is of crucial importance, whether it
is possible for the individual to express sui-
cidal feelings openly, or if there is a repres-
sive and tabooing climate not prepared to
share or listen to the problems. This touches
on how to deal with attitudes in a preven-
tional and interpersonal context. Among young
women, there is probably a relatively high
correspondence between the attitudes in the
surrounding peer group and that of a suicidal
person, giving a climate where it is possible
to talk about the problem. However, we
know too little about what is protective and
what is provoking in such a situation to draw
any definite conclusions on what constitutes
a preventive situation. Further research is war-
ranted.
To interpret attitude changes over
time, the role of more general or official sui-
cide prevention strategies have to be consid-
ered. In Sweden, as in many other western
countries, a great number of initiatives in the
field of suicide prevention have been taken
during the last two decades, and a national
program for suicide prevention was estab-
lished in 1995. The program was followed by
a more general activity in the field of suicide
prevention, and among other things attitudes
towards suicide were addressed in a public
health context. Therefore, the attitude changes
might be due partly to the increased efforts
in the suicide prevention area, that after so
many years of tabooing there is an ongoing
change in attitudes toward suicide—not only
concerning permissiveness, but also concern-
ing prevention.
Conclusions
The current study shows that it is pos-
sible to approach the general population with
a postal questionnaire on attitudes toward
suicide, reflected in the relatively high re-
sponse rates. This study demonstrates that at-
titudes toward suicide is not just a matter
of hostility-sympathy or liberalization-re-
RENBERG AND JACOBSSON
pression, but consist of various domains, espe-
cially concerning preventional issues. Data
also show that the direction of the association
between suicide and suicidal behaviors and dif-
ferent attitudes toward suicide varies according
to subgroup, type of behaviors and aggregated
or individual levels. The results speak in fa-
vor of two divergent hypothesis:
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Manuscript Received: July 2, 2001
Revision Accepted: July 1, 2002