key: cord-0853771-r2utdc9x
authors: Pretorius, Tyrone B.; Padmanabhanunni, Anita; Stiegler, Nancy; Bouchard, Jean-Pierre
title: Validation de l'Échelle de la Peur de la COVID-19 en Afrique du Sud : trois analyses complémentaires
date: 2021-10-21
journal: Ann Med Psychol (Paris)
DOI: 10.1016/j.amp.2021.10.010
sha: 7d5205d2b2de35418e749396195562ee49d462e9
doc_id: 853771
cord_uid: r2utdc9x

Fear is the most common response to disease outbreaks. Persistent and prolonged fear can elevate the levels of psychological distress and aggravate preexisting mental health problems. Therefore, prompted by the central role of fear in psychological responses to COVID-19, the Fear of COVID-19 Scalewas developed, which is the only instrument that can assess emotional fear reactions in relation to the current pandemic. In this study, we extend research on the psychometric properties of this instrument by adopting three complementary approaches: classical test theory, Rasch analysis, and Mokken analysis. Combining these methods allows for a more nuanced overview of the psychometric properties of the instrument. The sample comprised South African teachers (N = 355) who completed the Fear of COVID-19 Scale. All three approaches confirmed the reliability and the construct, convergent, and concurrent validity of the scale as used with South African teachers. In addition, all three approaches confirmed that the scale is sufficiently homogenous to be considered unidimensional. La peur est la réponse la plus courante aux épidémies. Une peur persistante et prolongée peut augmenter les niveaux de détresse psychologique et aggraver des problèmes de santé mentale préexistants. Dans le cas de la pandémie de la COVID-19 qui sévit depuis presque deux ans, la peur intense du virus SARS-COV2 et celle d'être à proximité de ceux qui sont infectés par le virus s'est avérée être associée au développement de symptômes de stress post-traumatique. Par conséquent, motivée par le rôle central de la peur dans les réponses psychologiques au COVID-19, l'échelle de la peur du COVID-19 a été développée, et est le seul instrument capable d'évaluer les réactions émotionnelles de peur par rapport à la pandémie actuelle. Dans cette étude, nous étendons la recherche sur les propriétés psychométriques de cet instrument en adoptant trois approches complémentaires : la théorie classique des tests, l'analyse de Rasch et l'analyse de Mokken. La combinaison de ces méthodes permet une vue d'ensemble plus nuancée des propriétés psychométriques de cet instrument. L'échantillon des personnes étudiées qui ont rempli l'échelle de la peur de la COVID-19, comprenait 355 enseignants du primaire et du secondaire, sud-africains, résidant principalement dans la province du Cap Occidental. Les trois approches ont confirmé la fiabilité et la validité conceptuelle, convergente et concurrente de cette échelle utilisée avec les enseignants sud-africains. De plus, les trois approches ont confirmé que l'échelle est suffisamment homogène pour être considérée comme unidimensionnelle.

intense fear of COVID-19 and of being in the vicinityof those who are infected with the virus has been found to be associated with the development of posttraumatic stress symptoms [37] .

Given the central role of fear in psychological responses to pandemics, various instruments have been developed to assess fear and anxiety toward disease outbreaks. To our knowledge the Fear of COVID-19 Scale (FCV-19S) [1] is the only measure developed specifically to assess fear of COVID-19. The initial version of the scale was developed in Persian [1] and was subsequently translated into over 15languages (e.g., Hebrew [4] ; Turkish [10] ; Spanish [20] ). It has also been used in diverse cultural contexts (e.g., Greece [38] ; India [5] ; Japan [41] ; Bangladesh [30] ) and demonstrated sound psychometric properties ( = 87; [30] ; [38] ; [41] ).

In arecent South African study, researchers assessed the psychometric properties of the FCV-19S [18] using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) and reported that the scaledemonstrates a unidimensional factor structure and sound internal consistency reliability (α = .87,ω = .88) when used witha sample of university students.In the current study, we aim toextend this workby assessing the psychometric properties and dimensionality of the FCV-19S as used with teachersin the South African context withthree different but complementary approaches:classical test theory (CTT), Rasch analysis (a parametric item response theory), and Mokken analysis(a nonparametric item response theory).In general, combining these methods allows for a more nuanced overview of the psychometric properties of an instrument [22] . While CTT allows computing a score for the FCV-19Sand offers a global view of the respondents' fear towardCOVID-19, the greater diagnostic power of Rasch and Mokken analyses allows identifying the items that are more likelyto be endorsed by respondents with different levels of fear [22] [26] [45] .This can [45] . Generally speaking, this type of information is important for identifying the significance of fear among various population groups as well as for targeted intervention efforts [25] .

Our participants were a convenience sample of 355 school teachers in South Africa.

The majority of the sample werefrom the province ofthe Western Cape (82.3%), were female (76.6%), taught ata primary schoollevel (61.1%), and lived in an urban area (61.7%). The mean number of years that the participants spentin the teaching profession was 15.7 (SD = 11.8), whereasthe mean age of the sample was 41.9 years (SD = 12.4).

In addition to a demographic survey, the participants completed the FCV-19S [1] and the Perceived Vulnerability to Disease Scale (PVD-Q) [7] . The FCV-19S consists of seven items that measure emotional fear reactions toward the pandemic on a five-item Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). The total score ranges between sevenand 35, with a higher sum score indicating a higher level of fear ofCOVID-19.

The PVD-Q is a 15-item self-report instrument consisting of two subscales. The first subscale assesses beliefs regarding one's own susceptibility to infectious diseases (perceived infectability: PI) and comprises eight items, whereas the other subscale assesses emotional Page 6 of 27 J o u r n a l P r e -p r o o f 6 discomfort in contexts that are associated with a high potential for disease transmission (germ aversion: GA) and comprises seven items. The participants respond to each item on a sevenpoint scale ranging from strongly disagree to strongly agree. Overall, the PVDS has demonstrated high internal consistency (α = .90 [7] ; α =.73 [43] ) and has been used with different samples in diverse contexts (e.g., Japan [44] ; Germany [34] ).

An electronic web-based survey comprising a demographic survey, the FCV-19S and the PVD-Q was created using Google Forms and distributed to public school teachers in South Africaduring the period from April toJuly 2021 via social media platforms. In addition, the university of XXX's school liaison officer assisted with distributing the electronic survey to school teachers in the province via existing institutional networks.

Ethical approval for the study was grantedby the Humanities and Social Sciences Ethics Committee of the University of XXX (ethics reference number: HS21/3/8). All participants completed informed consent forms and were provided with the contact details for psychological counseling support in case completing the survey evoked distress.

CTT analyses focused on internal consistency (coefficient α), interitem correlations, corrected item-total correlation, standard error of measurement (SEM), average variance extracted (AVE), composite reliability (CR), and EFA (maximum likelihood). All of these J o u r n a l P r e -p r o o f 7 were obtained using IBM SPSS Statistics version 26for Windows (IBM Corp., Armonk, NY, USA). In addition, to examine the unidimensionality and concurrent validity of the scale, CFA with IBM SPSS Amosversion 26 (IBM Corp.) wasperformed. In general, a reliability coefficient of >.70, an interitem correlation of >.30,an item-total correlation of >.50 [9] , a small SEM, and an AVE of >.50 [8] are considered acceptable. With respect to the CFA, several fit indices were used to test the proposed unidimensional structure of the FCV-19S, and concurrent validity was examined in terms of the relationship of the FCV-19S with PVD-Q. As suggested by Kline [14] , the selected indices included the root-mean-square error of approximation (RMSEA, best if close to .08 or less), comparative fit index (CFI, best if close to .90 or greater), goodness-of-fit index (GFI, best if close to .95 or greater), and Tucker-Lewis index (TLI, best if close to .95 or greater; [13] . In addition, the Akaike information criterion (AIC), which allows for model comparisons, was included [2] . In general, the model with the lowest AIC value is considered to have the best fit. With respect to the CFA, two models of the structure were examined, namely, a one-factor model and a bifactor model, in which theFCV-19S was conceptualized as consisting of two subscales as well as a total scale.

In addition, bifactor indices were calculated using the Bifactor Indices Calculator [6] . These indices include the explained common variance (ECV), which refers to the percentage of variance accounted for by the general factor; theomega hierarchical (OmegaH), which indicates the percentage of variance in total scores that is due to individual differences in the general factor;and thepercentage of uncontaminated correlations (PUC), which measures the number of unique correlations among items that can be explained by the general factor. An OmegaHof >.80 means that the scale is essentially unidimensional [29] . It hasalso been suggested that the ECV, OmegaH, and PUC should be considered together to draw conclusions regardingthe dimensionality of an instrument. In this regard, Reise et al. [28] suggested that a PUC of <.80, together with a general ECV of >.60 and Omega Hof >.70, Rasch analysis was performed using Winsteps version 5.1.4 [16] . Thisincluded the infit and outfit mean square (MnSq), item and person separation index, and item and person separation reliability, as well as the eigenvalue of the unexplained variance of the "firstcontrast" obtained through a principal component analysis (PCA) of the residuals.

Linacre [17] suggests that mean square values between 0.5 and1.5 are optimal, whereasperson separation should ideally have an index of >2 andreliability of >.8, demonstrating that the items can differentiate between different respondents. Item separation, however, confirms the item hierarchy (construct validity) of the instrument and should ideally have an index of >3 andreliability of >.8.Finally, it has beensuggested that the presence or absence of unidimensionality in the Rasch analysis depends on the size of a possible second dimension, referred to as the first contrast. In this regard, the eigenvalue associated with a possible second dimension should ideally be <2.

Mokken analysis was performed with R (R Core Team, 2017) using the "Mokken"

package [39] [40] .This analysis allows determining the unidimensionality, monotonicity, invariant item ordering (IIO),and reliability (MSRho). In terms of unidimensionality, Mokken analysis provides a scalability coefficient (H) for the total scale and one for each item (Hi).

The following rule of thumb is typically applied whenevaluating H-coefficients: H≥ .50 represents astrong scale,.40 ≤H< .50 represents amedium scale, and.30 ≤H< .40represents aweak scale [42] . In addition to the scalability coefficient, the Mokken package in R provides Table 1 Factor analysis resulted in one factor extracted explaining 59.64% of the variance. All factor loadings (.74 to .82) and item-total correlations were found to be significant (.68 to .77), indicating that all items contributed significantly to the scale. All interitem correlations were above .30 (.44 to .71), providing some evidence for construct validity. The infit and outfit MnSq values were found to range from0.88 to 1.16, thus falling within the range of 0.5 to 1.5, which isdeemed optimal. The Hi index for all items ranged between .62 and .67,which is above the ruleofthumb of .30 proposed by Mokken [23] .Similar to the item-total correlation, these Hi values demonstrate that all items contribute to the measurement of the latent variable, namely,fearof COVID-19. Table 2 here ------------------------ Table 2 showsthat the indices of reliability can be considered very good (α = .91, CR = .91, MSRho = .92) and that AVE is above the .50 level (AVE = .60), which is considered acceptable. In addition, the SEM found can be considered to be low (SEM = 2.12). It is also possible to consider the Rasch indices as satisfactory;for instance, theperson and item properties of the FCV-19S, as the literature indicates that even psychometric models that do not imply IIO may still be useful [31] .

Since the Rasch analysis suggested an additional dimension consisting of three items, CFA was used to compare a one-factor model of the FCV-19S with a bifactor model consisting of one general factor (total scale) and two specific factors (subscales). As suggested by the Rasch analysis, the three items that clustered together ("hands clammy," "cannot sleep," and "heart races") appear to reflect physiological fear reactions as opposed to the other four items that reflect emotional fear reactions. As such, the bifactor model conceptualized the FCV-19S as consisting of a total scale score (fear of COVID-19) as well as two subscale scores, namely, physiological fear reactions and emotional fear reactions. Table 3 shows the goodness-of-fit and bifactor indices resulting from the CFA. Table 3 here 

The aim of this study isto extend existing research on the FCV-19S by examiningitspsychometric properties, including its reliability, validity, and dimensionality, using three different complementary approaches, namely, CTT, Rasch analysis, and Mokken analysis. Since each of these approaches hasits ownstrengths and limitations, combining them provides a comprehensive picture of the reliability, validity, and dimensionality of the scale [22] .

All reliability indices were found to be satisfactory. The scale also demonstrated satisfactory internal consistency (coefficient αand MSRho), and the Rasch analysis confirmed that the scale can distinguish between different levels of "performers" (person separation reliability) and that a hierarchy of items exists (item separation reliability).

With regard to dimensionality, EFA and CFA confirmed that the scale can be considered unidimensional. In terms of the Rasch analysis, a PCA of residuals indicated that significant varianceis explained by the Rasch dimension (64.2%, eigenvalue = 12.57) and showed that the scalability coefficients (H and Hi) were all above the suggested threshold, indicating that the scale is sufficiently homogenous.Overall, the resultsobtained from the three approaches represent acceptable evidence of a unidimensional structure for the FCV-

In terms of convergent validity, Ghadi [8] suggested that factor loadings obtained in CFA, CR, and AVE provide a basis for decisions regardingconvergent validity. Notably, the factor loading associated with the FCV-19S, which was above .68, the CR of .91, and the AVE of .60 provide evidence of convergent validity.

The construct validity of the FCV-19S can also be considered satisfactory. According to Hajjar [9] ,an item-total correlation of>.50 and an interitem correlation of>.30 provide evidence of construct validity. In the current study, both the interitem correlations and itemtotal correlation exceeded this threshold. The item separation indices in the Rasch analysis provide further evidence of construct validity. For instance, Linacre (2021b) suggested that when the item separation index is >3 and theitem separation reliability is >.9, this confirms the existence of an item difficulty hierarchy, which evidences construct validity. However, the item separation indices obtained in the current study exceed these suggested values.

Moreover, the infit and outfit MnSq values were also within the acceptable range, providing further evidence of validity. Finally, concurrent validity was demonstrated through the association betweenfear of COVID-19 and the two subscales of PVD-Q, namely, germ aversion and perceived infectability.

In general, while fear is typically an adaptive and transient response to threat, disease outbreaks can prolong fear and enhance psychological distress [5] . Fear ofCOVID-19 has been associated with anxiety and mood disorders and has been found to aggravate preexisting mental health problems [11] . Furthermore, fear ofcontagion as well as discrimination and stigma directed toward infected individuals or those perceived to be responsible for the spread of COVID-19 can potentially fragment communities [12] . Hence, there is a need for methodologically sound instruments that are capable of identifying distinct markers of fear among population groups for targeted interventions, such as public education and health campaigns [24] .

This study had certain limitations. First, although the survey was anonymous, which should encourage disclosure, the potential impact of self-reporting bias needs to be acknowledged [38] . Second, it is unclear how the sample would generalize to teachers in other contexts. Therefore,future studies using a larger and more diverse sample are needed to replicate these results.

In this study, we demonstrated that the FCV-19S is a unidimensional scale with sound psychometric properties. Our findings complement, support, and extend previous studies on the psychometric properties, validity, and reliability of thisinstrument forsamples from diverse contexts. 

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