key: cord-0733860-zk0l7km6
authors: Mahmood, Qaisar Khalid; Jafree, Sara Rizvi; Qureshi, Waheed Ahmad
title: The Psychometric Validation of FCV19S in Urdu and Socio-Demographic Association with Fear in the People of the Khyber Pakhtunkhwa (KPK) Province in Pakistan
date: 2020-07-12
journal: Int J Ment Health Addict
DOI: 10.1007/s11469-020-00371-4
sha: c6e1370b67b6995d93d1c28fb18d153e184aca24
doc_id: 733860
cord_uid: zk0l7km6

This study rests on two important considerations: the rapid increase of COVID-19 cases in Pakistan and also the marginalization of the people of the KPK province, which would make them more vulnerable in fearing COVID-19. We aim to translate and validate FCV-19S into the Urdu language and to identify the socio-demographic associations with fear in the people of the KPK. Using an online Google survey, we were able to sample 501 respondents from the KPK. The Cronbach alpha α value for the Urdu FCV-19S displayed good internal reliability at .846. The unidimensional structure of the FCV-19S in Urdu was confirmed, and all of the items were found to be statistically significant, ranging from 0.59 to 0.80. The results of the confirmatory factor analysis show that fit indices are all within an acceptable limit. The FCV-19S was also significantly and positively correlated with preventive behavior (r = .328, p < .01) and general anxiety (r = .458, p < .01). The results of independent sample t tests show that women (t = 4.086, p < 0.001), married people (t = − 2.709, p < .001), and unemployed people (t = − 3.199, p < 0.001) of the KPK experienced great fear of COVID-19. We conclude that that the Urdu version of the FCV-19S is a valid and reliable tool and must be used by healthcare practitioners, government bodies, and researchers, to identify the prevalence of fear and to subsequently plan improved social and health policies to reduce anxiety in the public.

about the objectives of the study in a cover letter, and informed consent was taken electronically. The researchers ensured that all of the participants were made aware about the anonymity and confidentiality of their data. No survey could be submitted unless every question had been answered. In total, there were 501 respondents who successfully completed this survey. The respondents were not offered any incentive to participate in this study.

In order to see the effect of socio-demographic variables, the survey included questions related to age, gender, educational status, employment status, current place of residence, and marital status.

The FCV-19S scale consists of 7-items (e.g., item 2, "It makes me uncomfortable to think about Corona" and item 5, "I cannot sleep because I'm worrying about getting Corona") measured on a 5-point Likert scale. The 5-point Likert-scale (1 = strongly disagree to 5 = strongly agree) was used to report the responses of the respondents (Ahorsu et al. 2020) . The original scale showed extremely good internal consistency (α = .82). The FCV-19S scale has been validated in other languages and is now available in the Italian version (α = .87) (Soraci et al. 2020) , the Bangla version (α = .87) (Sakib et al. 2020) , the Turkish version (α = .84) (Satici et al. 2020) , the Russian version (α = .80) (Reznik et al. 2020) , the Arabic version (α = .88) (Alyami et al. 2020) , and the Greek version (α = .87) (Tsipropoulou et al. 2020) .

In accordance with established protocols for cross-cultural adaptation, the researchers opted for the forward-backward translation method to develop the Urdu version of the FCV-19S scale (Alyami et al. 2020; Yu et al. 2004 ). In the first phase, the original FCV-19S in English was given to an autonomous linguist who was familiar with both languages. The expert translated all of the items into Urdu. In the second phase, one of the authors, who is fluent in English and Urdu, evaluated the Urdu translation and provided feedback to the linguist. After receiving the forward translated Urdu version of the FCV-19S, this scale was again translated back into English by another author who, at this time, was unfamiliar with the original English scale. Both the forward and backward translations of the scale were assessed and evaluated for cultural appropriateness among the authors. A pilot study (n = 27) was conducted to see if any changes were required. The findings of the pilot test confirmed that there were no further changes required.

According to available knowledge regarding coronavirus and the recommendations given by World Health Organization (World Health Organization 2020), the researchers developed seven statements to measure preventive behavior related to COVID-19. The items included the following: "I regularly wash my hands for 20 seconds"; "I wear a mask when I go outside";) "I avoid shaking hands as a form of greeting"; "I maintain social/ physical distance while meeting others"; "I avoid people who have a cough or flu"; and "I do not touch my face, mouth, nose, or eyes without washing my hands". The Cronbach alpha of this scale was ά = .846, indicating good internal consistency.

The authors used seven items from the Generalized Anxiety Disorder (GAD) Questionnaire (Spitzer et al. 2006) to measure anxiety disorder among respondents. The seven items used from the scale describe a number of the most salient diagnostic features of GAD (i.e., feeling nervous, anxious, or on edge and worrying too much about various things). Items are rated on a 4-point Likert-type scale (1 = not at all to 4 = nearly every day). The Cronbach alpha of this scale was (ά = .892), indicating good internal consistency.

The authors used IBM SPSS Statistics 21 to perform statistical analyses. Descriptive statistics were used to report the sample characteristics. Measures of central tendency (mean and standard deviation) and measures of distribution (skewness and kurtosis) were calculated with respect to each item. To assess internal consistency of the FCV-19S in Urdu, we computed a Cronbach alpha coefficient (α), inter-item correlations, and corrected item-total correlations. We also assessed concurrent validity of the FCV-19S in Urdu by comparing the Pearson correlations between the FCV-19S and preventive behavior related to COVID-19, FCV-19S, and general anxiety disorder (GAD).

For confirmation of the unidimensional factor structure of the FCV-19S in Urdu, the authors conducted a confirmatory factor analysis (CFA) using the maximum likelihood estimation (MLE) method. AMOS software was used for this purpose. Goodness of fit was assessed according to the following criteria: goodness of fit index (GFI < .90); adjusted goodness of fit index (AGFI < .90); comparative fit index (CFI > .90); and root mean square error of approximation (RMSEA ≤ .08) (Lei and Wu 2007) .

Of the 501 respondents, 293 (58.5%) were male and 208 (41.5%) were female, with approximately 61% living in urban areas (Table 1 ). The majority of the participants (54.5%) belonged to the age group of 26-50 years followed by 38.9% who were aged up to 25 years. Most of the respondents were either graduates (41.5%) or post graduates (46.9%). The study population had almost equal representation of unmarried and married people, and more than half of the respondents (56.7%) were unemployed.

In Table 2 , the measures of central tendency, skewness, and kurtosis of each item are reported.

The results indicate that people had agreement with items 1, 2, and 5, whereas they disagreed with items 3, 4, 6, and 7. According to Byrne and Campbell (1999) , a distribution of items can be considered normal if values of skewness and kurtosis range between + 1.5. Our findings show that all of the items were normally distributed because no item had a higher or lesser value than + 1.5 for skewness and kurtosis.

The results of the inter-item correlations are presented in Table 3 . According to Ferketich (1991) , if inter-item correlations and corrected item-total correlations are between .30 and .70, associations between the items are considered as medium to strong. All inter-item correlations were found to be significant and ranged between 0.333 and 0.738. The value of Cronbach's α equaling .70 or higher indicates acceptable reliability (DeVellis 2016). Cronbach's α for the Urdu version of the FCV-19S was reported as .846 (Table 4 ). Corrected item-total correlations ranged between .493 and .732. Moreover, the value of Cronbach's α for the Urdu version of the FCV-19S does not go down if any item is deleted from the scale (see Table 4 ). These results indicate that the Urdu version of the FCV-19S has really good internal consistency. A concurrent validity analysis was also conducted. There was a statistically significant and positive correlation (r = .328, p < .01) between the FCV-19S and preventive behavior related to COVID-19. Similarly, the FCV-19S was also positively correlated with the general anxiety disorder (r = .458, p < .01).

A confirmatory factor analysis was performed to assess the single factor structure of the Urdu version of the FCV-19S scale ( Table 5 ). The results show that fit indices are all within the acceptable limit: [χ 2 (9, N = 501) = 32.101, p < .05; RMSR = .037; RMSEA = .072; GFI = .982; AGFI = .944; TLI = .967; CFI = .986]. The factor loadings of the Urdu version of the FCV-19S were found to be statistically significant, ranging from 0.59 to 0.80. We also calculated AVE and CR for the Urdu version of the FCV-19S. The values of AVE = .50 and CR = .874 indicate an evidence of construct reliability (Fig. 1 ).

The results of an independent sample t test and a one-way ANOVA are presented in Table 6 . The findings show that there is a statistically significant mean difference (t = 4.086, p < 0.001) in the FCV-19S between males (M = 17.73, SD = 5.31) and females (M = 19.76, SD = 5.72). Female respondents were more frightened due to the outbreak of novel coronavirus compared to male members of the society. There were also significant mean differences (t = − 2.709, p < .001) between married (M = 19.24, SD = 5.3) and unmarried people (M = 17.90, SD = 5.20) in FCV-19S. We also found that unemployed people had higher scores on the FCV-19S compared to employed people. The findings also indicate that young adults had higher scores on the FCV-19S than middle-aged and elderly people. 

It is critical to mitigate fears of COVID-19 in order to better plan prevention and mitigate the health and social consequences of fear and anxiety in people, especially the vulnerable and .967 > .90 Root mean square error of approximation (RMSEA)

.072 < .08 Root mean square residual (RMSR)

.037 < .08 Average variance extracted (AVE)

.500 > .50 Composite reliability (CR) .874 > .60 Our study has its limitations in that we were dependent on online sampling, and, therefore, the results may not be generalizable. In addition, the responses are based on perceptions, and there may be a source bias effect. However, this study has its strengths, in that it has confirmed the use of this scale in Urdu. The majority of people across Pakistan speak the official Urdu language despite the presence of multiple provincial languages throughout the country (Rahman 2006 ). It would not be wrong to say that the Urdu language has revived in recent years due to post-Colonial and nationalistic debates (Shamim 2008) . The ability to type in Urdu on social media platforms and promote Urdu through digital means has also increased cultural attachment in the population and has facilitated increased usage. Overall, our findings are similar to previous research using the FCV-19S scale. The internal consistency of the Urdu version of the FCV-19S was .846, which is slightly higher than that reported for the original scale (α = .82) (Ahorsu et al. 2020 ). However, this value is less than that reported for Italian (α = .87) (Soraci et al. 2020) , Bangla (α = .87) (Sakib et al. 2020) , Turkish (α = .85), (Satici et al. 2020) , and Arabic versions (Alyami et al. 2020 ). Our study also shows that the Urdu version of the FCV-19S scale has good concurrent validity, as demonstrated by a significant positive correlation with preventive behavior related to COVID-19, and general anxiety disorder, as well as acceptable construct validity, as demonstrated by the CFA results.

We now recommend repeat and longitudinal studies across the country, in order to facilitate identification of the prevalence of fear and policy planning for the alleviation of fear, and the training of healthcare practitioners, government officers, legal authorities, media, civilians, and the online community in helping to reduce fear and anxiety in the public.

We also found in this study that the following socio-demographic groups in the KPK province experience great fear of COVID-19: women, married people, unemployed people, and younger people. Gender research from the KPK confirms that women generally experience more fear when faced with health problems, due to the following: permission and mobility issues related to (Ali et al. 2016; Saeed and Farooq 2017) ; low literacy, and lack of health awareness and health information (Khan et al. 2013) ; poverty and financial barriers to health access (Qureshi et al. 2012) ; and the inherent maternal instinct and care emotions felt for family and children when risk of infection and disease is high (Shagufta and Shams 2019) . Married people may suffer fear in times of pandemic and national uncertainties due to deterioration in family life and wellbeing (Ornell et al. 2020) , risk of violence and abuse (Peterman et al. 2020) , employment, loss of family income and household food insecurity (Loopstra 2020) , and loss of spouse or fertility (Okwun and Siraj 2010) . With regard to unemployed people, they may experience great fear due to a reduced possibility of being recruited due to the decline in economic activity caused by lockdown and social distancing (Mamun and Ullah 2020) . We recommend serious attention to support and alleviate the fears of disadvantaged populations during and after the pandemic. Certain critical areas that require attention include income generation and cash transfers, job stability and inflation control, and online counseling and therapy. It is also recommended that further studies attempt to include more socio-demographic characteristics related to co-morbidity and multi-morbidity in order to assess if the fear is also due to current and previous health burden. Variables related to "fear of public stigma" and "having a relative with COVID-19" may also be useful in identifying other factors that may influence fear and also in ascertaining any moderating effects on fear.

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Acknowledgments We acknowledge friends and colleagues who helped us circulate this survey in difficult times as well as the respondents. We are also indebted to the linguistic expert who assisted us in translation.

Conflict of Interest The authors do not have any conflict of interest.Appendix A