key: cord-0942372-3ev6b7j8
authors: Basit, Khalid Abdul; Zafar, Awn Bin; Fawwad, Asher; Waris, Nazish; Shaheen, Fariha; Basit, Abdul
title: The fear of COVID and depression in patients with diabetes at a tertiary diabetes care center in Karachi, Pakistan
date: 2021-03-18
journal: Diabetes Metab Syndr
DOI: 10.1016/j.dsx.2021.03.008
sha: bdcfd2cc7c4ae35e8602d6abaf8e97969c58f301
doc_id: 942372
cord_uid: 3ev6b7j8

BACKGROUND AND AIMS: To assess the psychometric properties of the Fear of COVID-19 (FCV–19S) scale and to determine its associated factors among the Pakistani patients with diabetes. METHODS: This observational study was conducted in 24-h helpline service, a department of Baqai Institute of Diabetology and Endocrinology (BIDE). Study duration was from August to September 2020. The target population was registered adult patients with type 2 diabetes aged >16 years. Baseline demographic details were obtained from hospital management system of BIDE. Forward-backward translation method was used to translate the existing Fear scale (FCV–19S). Symptoms of depressive disorder were assessed through Patient Health Questionnaire (PHQ9). RESULTS: Total of 380 participants with mean age 51.93 ± 12.03 years were contributed in study. Three factors loading and item correlation of fear COVID-19 explained 96% of total variance having unidimensional Cronbach's alpha of 0.881. All demographic indicators that showed significance in univariate model were included in multivariate model. Females had more fear for COVID-19 compared to males (OR = 1.73, 95% CI (1.15–2.6)), whereas current smokers had also showed 4 times more fear than non-smokers (OR = 4.19, 95% CI (1.18–14.83). Depression assessed by PHQ9 showed maximum fear of COVID-19 in participants with moderate depression. CONCLUSION: FCV-19S had adequate psychometric properties for assessing effects of pandemic in people with diabetes attending tertiary care center.

To assess the psychometric properties of the Fear of COVID-19 (FCV-19S) scale and to determine its associated factors among the Pakistani patients with diabetes.

This observational study was conducted in 24-hour helpline service, a department of Baqai Institute of Diabetology and Endocrinology (BIDE). Study duration was from August to September 2020. The target population was registered adult patients with type 2 diabetes aged >16 years. Baseline demographic details were obtained from hospital management system of BIDE. Forward-backward translation method was used to translate the existing Fear scale . Symptoms of depressive disorder were assessed through Patient Health Questionnaire (PHQ9).

Total of 380 participants with mean age 51.93 ± 12.03 years were contributed in study. Three factors loading and item correlation of fear COVID-19 explained 96% of total variance having unidimensional Cronbach's alpha of 0.881. All demographic indicators that showed significance in univariate model were included in multivariate model. Females had more fear for COVID-19 compared to males (OR=1.73, 95% CI (1.15 -2.6)), whereas current smokers had also showed 4 times more fear than non-smokers (OR=4.19, 95% CI (1. 18-14.83 Diabetes and mental health conditions are established synergistic epidemic with impact of biological, social, and psychosocial factors on general health outcomes 5 . Not-surprisingly, there is a growing concern for consequences of environmental stress as this pandemic on mental health especially psychological strain for self-management in people with diabetes in this unprecedented situation 6, 7 . The umbrella review of South Asian studies has reflected the existing prevalence of depressive disorders, which is anticipated to be around 38% in diabetic population, though the impact of external additional stress of COVID19 is yet undetermined 8 .

However, considering this contextual concern, Ahorsu et al developed a Fear of COVID-19

Scale (FCV-19S), a rigorous psychometric testing tool to indicate the fear in populations 9 . The scores were categorized into five groups such as no depression (0-4), mild depression (5-9), moderate depression (10) (11) (12) (13) (14) , moderately severe depression (15) (16) (17) (18) (19) and severely severe depression (20) (21) (22) (23) (24) (25) (26) (27) 11 . The participants with overall PHQ-9 score of 15 and above were considered for the primary physician review for further management.

All analysis was done using Stata/SE 15.0 for Windows (64bit x86-64). Descriptive statistics as mean ± SD and frequencies with percentages were reported for continuous and categorical data respectively. Descriptive including skewness and kurtosis were also reported, whereas percentage of participants obtaining the highest and lowest possible scores were considered as floor and ceiling, respectively. Psychometric analysis of the scale was performed using two approaches, classical test theory (CTT) and modern test theory (MTT). Item response theory (IRT) using graded response model (GRM) was used to report discrimination and difficulty for the likert scoring items of fear COVID-19 questions. CTT analysis included internal consistency (Cronbach's α) and confirmatory factor analysis (CFA) was also reported. Total of 380 participants with mean age 51.93 ± 12.03 were recruited in the study. Out of total 205 (53.9%) were males and 175 (46.05%) were females. Almost 92% females were housewife whereas out of males, 12% were associated with business, 11.8% were professional and 15%

were from labor work. Participants with previous history of smoking or tobacco were 18% whereas 4.5% were observed as current smokers. Depression measured using PHQ9 showed 22.6% of study participants with mild depression and 2.63% had moderate depression (Table 1) . Table 2 represented descriptive statistics including mean, SD, skewness and kurtosis for all 7

Fear COVID-19 items along with floor and ceiling percentages. Table 3 characterized the factor loadings and item correlation of fear COVID-19 according to the factor obtained from the analysis. These three-factor explained 96% of the total variance, where factor 1 explaining 80% of the variance, factor 2 explaining 10% and factor 3 explaining 6% of the variance. A reliability analysis for unidimensional and a three-factor model stated a Cronbach's alpha of 0.881 for unidimensional, 0.9 for factor 1, 0.924 for factor 2 and 0.679 for factor 3 respectively. Average variance extracted (AVE) was 0.632 and composite reliability (CR) was 0.922 and were acceptable. Table 4 represented the univariate and multivariate logistic regression analysis. The outcome variable (COVID-Fear) was computed as binary variable using count of any response as "agree" or "strongly agree" for fear questions. The significant association of presence of fear regarding COVID-19 was seen in females, current smokers and participants with depression (p<0.05).

Females had approximately 2 times more fear for COVID-19 compared to males (OR=1.73, 95% Comparing demographic factors, females showed approximately twice more fear for COVID-19 compared to males, current smokers showed 4 times more fear than non-smokers also similar to previous reported data 13 . Our results oppose to Ahorsu et al., study who presented that gender J o u r n a l P r e -p r o o f had no effect on the FCV-19S. 9 However, age and socioeconomic status showed no effect on FCV-19S, can be relied upon to assess and deal with the psychological issues emanating from COVID-19 among individuals of all ages and any socioeconomic state. Our results opposed earlier study which showed significant correlation for younger age and higher education levels towards higher coronavirus anxiety scale (CAS) 14 .

Previously, it was reported that fear triggers psychological reactions and help people to respond to a threatening agent 15 . We assessed depression using PHQ9, showed the maximum fear of COVID-19 in participants with moderate depression, thus indicating participant's depression was significantly associated with fear of COVID-19 and concerns regarding lockdown. Our results are similar to Iranian, Italian and Bangla validation studies, who reported significant positive associations between depression and FCV-19S score 10,12,16, . In previous study, the FCV-19S was significantly correlated with depression, anxiety, perceived infectability, and germ aversion also suggesting that individuals with severe fear of COVID-19 may have these underlying comorbid disorders 17. The Centers for Disease Control and Prevention (CDC) had also reported that fear and anxiety of COVID-19 patients can be overwhelming about their health 18 . Psychological disorders such as symptoms of depression are more likely to developed due to lack of clarity about different risk levels including privacy concerns, treatment plans and difficulty in approaching to physician 19, 20 . We are also in agreement with previous studies that showed unclear statement as "to whether being depressed heightens the fear concerning COVID-19 or whether the fear concerning COVID-19 heightens depression (or both)" 21 .

In conclusion, depression assessed by PHQ9 showed the maximum fear of COVID-19 in participants with moderate depression suggesting that FCV-19S has good psychometric J o u r n a l P r e -p r o o f properties and can be utilized in studies assessing the effects of the pandemic in people with diabetes visiting tertiary care center in Pakistan.

We used convenience sampling and no formal diagnosis on mood disorders e.g., anxiety, so the sensitivity and specificity of the scale was not determined and is in our limitations Also this is a single centered study so the findings could not be generalized to whole population. Further multicentered studies in patients with diabetes and in the general population are needed. In our study, single-factor structure of the scale was based, though confirmatory factor analysis on its factor structure are still essential.

The authors declare that they have no conflicts of interest.

No funding sources. J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f 

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