key: cord-0999241-81ijzz3a
authors: Perz, Catherine A.; Lang, Brent A.; Harrington, Rick
title: Validation of the Fear of COVID-19 Scale in a US College Sample
date: 2020-06-25
journal: Int J Ment Health Addict
DOI: 10.1007/s11469-020-00356-3
sha: 8d700e28ad4069634cda2f7690ec32e9a53f00b5
doc_id: 999241
cord_uid: 81ijzz3a

The COVID-19 pandemic has impacted college students’ coursework, stress levels, and perceived health. Various estimates indicate that high proportions of college students have experienced increased amounts of stress (Dziech, Inside Higher Education, 2020; Hartocollis, New York Times, 2020), yet other sources indicate that many college students respond to these changes with resilience (Kelley, Cornell Chronicle, 2020). A method for assessing student anxiety regarding the pandemic is thus needed. The Fear of COVID-19 Scale (FCV-19S) (Ahorsu et al., International Journal of Mental Health and Addiction, 2020) is a seven-item scale which has been validated and shown to possess good psychometric qualities in studies of participants from multiple countries. The current study used a cross-sectional convenience sample of US college student participants (n = 237) and found that the FCV-19S has high reliability and validity as demonstrated by its internal consistency and strong one-factor solution. Scores on the FCV-19S were positively correlated with anxiety for students who were married or of Asian descent. Additionally, the FCV-19S was only moderately correlated with the Generalized Anxiety Disorder-7 Scale (GAD-7), suggesting that the FCV-19S may bring added utility to research and clinical practice with populations impacted by the COVID-19 pandemic.

Saudi Arabia (Alyami et al. 2020) . In an Eastern European sample, however, Reznik et al. (2020) found a factor solution that was distinct from these clear one-factor solutions.

The essential purpose of this study was to examine the psychometric qualities of the FCV-19S in a sample of English-speaking US college students. We also wanted to explore construct validity further by examining the relationship between the FCV-19S and the GAD-7, a measure of generalized anxiety.

Participants were n = 237 undergraduate and graduate students at a small public university. Eligible participants were university students taking at least one graduate or undergraduate class. Students were recruited through announcements in online classes. (All university courses were online during this period due to the COVID-9 pandemic.)

Students completed a demographic questionnaire including gender, ethnicity, age, and several other demographic factors.

The Generalized Anxiety Disorder-7 (GAD-7) scale (Spitzer et al. 2006; Toussaint et al. 2020 ) is a seven-item scale developed for use in screening, diagnosis, and severity assessment for anxiety disorders which has strong psychometric qualities. It is a widely used measure in both research and clinical settings and has been used to evaluate students during the COVID-19 pandemic in at least one research project (Cao et al. 2020 ). In the present study, we found that the GAD-7 had excellent internal consistency reliability (α = 0.93).

The FCV-19S (Ahorsu et al. 2020 ) is a seven-item scale assessing anxiety regarding COVID-19. Items are endorsed on a 5-item Likert scale from 1 (Strongly Disagree) to 5 (Strongly Agree). Total scores range from 7 to 35.We used the English translation of the FCV-19S included in the original authors' work (Ahorsu et al. 2020 ) and changed several words to avoid confusion which might have resulted when using the items with this population of students. Item 1 (see Table 2 for a list of items) initially read, "I am most afraid of Coronavirus-19." "Most afraid" could be interpreted in this population as an absolute ranking of fears rather than noting strong fear, so we changed the wording to "Very afraid." Item 7 was originally, "I am afraid of losing my life because of coronavirus-19. "Losing my life" was changed to "dying" because the former is a less commonly used expression in American English. We believed these changes prevented error which could have come through participant misinterpretation. The FCS-19S scale used was otherwise identical to the Ahorsu et al. (2020) wording.

This study was approved by the University Committee for the Protection of Human Subjects. The procedures used in this study adhere to the tenets of the Declaration of Helsinki. Participants provided informed consent to participate. Students were recruited through an announcement provided by their instructor in online university classes from various subject areas. Students responded to the survey through Qualtrics. The median time to complete the survey was 7 min, 30 s. Block randomization of survey instruments was used to prevent order effects.

Descriptive statistics were used to examine the demographic characteristics of participants in the sample. Internal consistency reliability of the Fear of COVID-19 Scale was measured with SPSS Version 26 using Cronbach's alpha, inter-item correlations, and corrected item-total correlations. As recommended by Clark and Watson (1995) and Field (2009) , a Cronbach's alpha of 0.80 or higher, minimum inter-item correlations between 0.15 and 0.50, and minimum corrected item-total correlations of 0.30 were used as indicators of internal consistency reliability. Given that the present study was to our knowledge the first to use the Englishlanguage version of the Fear of COVID-19 Scale in a sample of US college students, we conducted an exploratory factor analysis (EFA) of the scale using SPSS Version 26. Additionally, we believed an EFA was more appropriate than a confirmatory factor analysis (CFA) because previous studies had not all found the same, one-factor solution across samples from different nations and languages. Furthermore, this is the recommended approach when conducting the first psychometric evaluation of a newly translated measure, regardless of the rigor of the translation method (Swami and Barron 2019) . Given the conceptual similarity among items, we assumed that if there were multiple factors, they would be correlated. Thus, we conducted a principal axis factor analysis with a direct oblimin rotation. Based on recommendations by Clark and Watson (1995) , we considered our sample size sufficiently large to conduct an EFA on the seven-item Fear of COVID-19 Scale. As recommended by Field (2009), we used a cutoff of the Kaiser-Meyer-Olkin (KMO) measure of ≥ 0.8 as empirical evidence of a sufficiently large sample size for factor analysis. Following the EFA, a simultaneous, multiple regression analysis was conducted to predict Fear of COVID-19 total scores from theoretically important predictors. A simultaneous multiple regression was chosen because of the limited amount of prior research on predictors of Fear of COVID-19 total scores to guide the ordering of predictors in a stepwise multiple regression.

As indicated in Table 1 , the 237 participants in the current sample were older than traditional college students (M = 30.3; SD = 10.2), which is reflective of the broader university from which the sample was drawn. Most participants were female (73%), single (59%), undergraduate students (89%), and most reported experiencing a negative financial impact by the COVID-19 response (73%). Similar to the broader university, participants in the sample were ethnically diverse, as most participants identified as Caucasian (30%), Hispanic (30%), African-American (17%), or Asian (9%). Most participants (58%) reported at least mild anxiety in the past 2 weeks on an anxiety screener (GAD-7).

As indicated in Table 2 , the Cronbach's alpha for the 7-item Fear of COVID-19 Scale was excellent, with an overall α = 0.91. Further evidence of the reliability of the scale was found in the very high corrected item-total correlations of all seven items in the scale (all rs ≥ 0.70). Also, as seen in Table 2 , there were moderate inter-item correlations among the seven items of the scale, which ranged from r = 0.52 to r = 0.72. Taken together, these three indicators are all above the recommend cutoffs suggested by Clark and Watson (1995) and Field (2009) and suggest that the Fear of COVID-19 Scale demonstrates excellent internal consistency reliability. a Note that percentages are based on the number responding to each question and may not add up to 100% due to rounding b Participants who did not fit any of the four categories chose "none of the above" c Response to item, "Has the COVID-19 pandemic or response to it negatively impacted you financially?" d Response to item, "Do you know anyone who has had symptoms of COVID-19?"

We obtained a KMO of 0.88, indicating a sufficiently large sample size for the EFA. The principal axis factor analysis revealed a single-factor solution, with an eigenvalue of 4.63 that explained 66% of the variance in the Fear of COVID-19 scores. As indicated in the scree plot in Fig. 1 , no other factors had eigenvalues > 1.0 and there was a clear bend after the first factor on visual inspection of the scree plot. As indicated in Table 2 , factor loadings were high (all loadings ≥ 0.70) and there were no cross-loadings of items on multiple factors. Taken together, the results of the EFA revealed a one-factor solution for the English language Fear of COVID-19 Scale with a US college sample.

As indicated in Table 3 , we conducted a simultaneous multiple linear regression predicting Fear of COVID-19 total scores from demographic characteristics (i.e., age, gender, ethnicity, marital status), mental health characteristics (i.e., GAD-7), and COVID-19 specific characteristics (i.e., knowing someone with COVID-19 symptoms; experiencing negative financial impact due to . Categorical variables were dummy coded with the most frequent category serving as the reference group. Thus, for gender, females served as the reference group; for ethnicity, Caucasians served as the reference group; and for marital status, single/ never married served as the reference group. As seen in Table 3 , only four predictors were significant. Regarding demographic predictors, participants of Asian descent reported significantly higher Fear of COVID-19 total scores than Caucasians (B = 4.45, SEB = 1.31, β = 0.18, p = 0.001). In addition, married or partnered participants reported significantly higher Fear of COVID-19 total scores than single participants (B = 1.76, SEB = 0.79, β = 0.13, p = 0.03). Furthermore, participants who knew someone with COVID-19 reported significantly higher Fear of COVID-19 total scores than those who did not know anyone with symptoms (B = 2.42, SEB = 0.79, β = 0.15, p = 0.003). Finally, in support of convergent validity, participants who scored higher on the GAD-7 had significantly higher Fear of COVID-19 total scores (B = 0.75, SEB = 0.06, β = 0.64, p < 0.001). As a follow-up analysis to support the construct validity of the FCV-19S, we also calculated the zero-order correlation coefficient between the FCV-19S Total Score and the GAD-7 Total Score. We found a significant and moderate correlation between the two, r = 0.68, p < 0.001.

The current study presented a psychometric evaluation of the Fear of COVID-19 Scale (FCV-19S) with a US college population. The results indicate that the scale has good internal consistency reliability, a finding consistent with previous research on the scale in a variety of other national samples (Ahorsu et al. 2020; Alyami et al. 2020; Reznik et al. 2020; Sakib et al. 2020; Satici et al. 2020; Soraci et al. 2020) . Additionally, these results showed that the scale has a single-factor structure, adding to the previous studies which also found this structure for the scale (Ahorsu et al. 2020; Soraci et al. 2020; Satici et al. 2020 ; Sakib et al. At the same time, the relationship between the FCV-19S and the GAD-7 also illustrates divergence. While the statistical results show correlation between the two, with higher scores on the GAD-7 predicting higher scores on the FCV-19S, the absolute value of the correlation was only moderate (r = 0.68). This suggests that there is significant unshared variance between the two scales and that they represent more than one underlying construct. This demonstrates that the FCV-19S may contribute some unique variance to the picture of overall anxiety.Whereas the GAD-7 focuses on generic experiences of anxiety regardless of source, the FCV-19S focuses solely on COVID-19 to the point of including the term "COVID-19" in each question. It brings to the picture a more specific topic focus-COVID-19-related concerns-and distinguishes them from items measuring overall emotional or experiential anxiety. The GAD-7, by design, measures more diffuse and general anxiety about an individual's daily experience, while the FCV-19S isolates the anxiety that is solely related to the current pandemic. Although the GAD-7 asks about the past 2 weeks, it is possible that the results of the current study may be emerging from a quasi "state/trait" relationship, with GAD-7 reflecting a more enduring trait-like experience, and the FCV-19S representing a more transient, quasi-state experience due to the momentary pandemic. In future research, testing this possibility using a validated measure of trait/state anxiety could help to answer this question.

Even without being able to fully identify the nature of the non-shared variability between the GAD-7 and the FCV-19S, these results do establish the added utility of the FCV-19 Scale in both research and clinical settings. For instance, rather than selecting relaxation training for general anxiety, a clinician may elect to choose cognitive-based treatment for COVID-19related content. Using the FCV-19S would help provide the specific information for clinical decision making of this kind.

The results of the present study also illuminate additional aspects of the predictors of COVID-19 anxiety. First, gender and age were not associated with differing levels of anxiety as measured by the FCV-19S. Nor was experiencing financial loss from COVID-19. Knowing someone with COVID-19 symptoms, on the other hand, was associated with greater anxiety among this student population. This may be due to the increased salience that may occur from encountering COVID-19 in one's own circle of acquaintances. Married students were more likely to be anxious than those who are not married. The reasons for this are not clear, but it is possible that married participants have more anxiety in that they worry not only about themselves, but for their partner's welfare also.

In this group, ethnicity was only associated with fear of COVID-19 for one group. Students of Asian descent scored higher than did Caucasians on the anxiety measure. Our data do not provide specific conclusive reasons to explain this finding. There is, however, a recent rise in anti-Asian racism associated with the putative origins of COVID-19 (Chung and Li 2020; Human Rights Watch 2020; Lin 2020). It is possible, thus, that an increasing climate of anti-Asian racism may be responsible for increased anxiety related to this topic in students of Asian descent. This is an open question which merits additional research.

These results come with limitations. Given that our population has strong representation of US ethnic minorities (70% non-Caucasian) and is somewhat older than traditional university samples (55% over the age of 25), it is not clear how this sample would generalize to all US university students. Given that this was a sample of a college population, it would also be useful to replicate on non-college populations. This was a cross-sectional study which does not provide information about the effects of time or history on COVID-19-related anxiety. As the pandemic and its social impacts develop, changes in social rules and norms result. Public health information evolves, and trust in various information sources may wax and wane as well. Longitudinal study of the FCV-19S would provide important information about how COVID-19-related anxiety changes with changing rates of infection and deaths as well as cultural and social responses to the pandemic. Understanding the long-term relationships between aspects of the pandemic, both medical and social, and resulting anxiety levels would be a fruitful and important course of research.

Author Contributions The first author conceptualized and designed the study and was involved in all stages of data analysis, interpretation, and manuscript writing. The second author managed the data, performed data analysis, and assisted with the manuscript writing. The third author assisted with the design of the study and manuscript writing.

Conflict of Interest The authors declare that they have no conflict of interest.

Informed Consent All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). Informed consent was obtained from all participants for being included in the study.

Active Minds (2020) COVID-19 impact on college student mental health

The Fear of COVID-19 Scale: development and initial validation

Psychometric evaluation of the Arabic version of the Fear of COVID-19 Scale

California Executive Order N-33-20

The psychological impact of the COVID-19 epidemic on college students in China

Coronavirus-19 (COVID-19) previous U.S. COVID case data

Anti-Chinese sentiment during the 2019-nCoV outbreak

Constructing validity: basic issues in objective scale development

Psychology graduate student pandemic workload report

What about the students? Inside Higher Education

Discovering statistics using SPSS

Scattered to the winds, college students mourn lost semester

Traumatic stress in the age of COVID-19: a call to close critical gaps and adapt to new realities

Covid-19 fueling anti-Asian racism and xenophobia worldwide

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Social reaction toward the 2019 novel coronavirus (COVID-19)

The fear of COVID-19 and its role in preventive behaviors

Assessing the fear of COVID-19 among different populations: a response to Ransing et al.(2020). Brain, Behavior, and Immunity

A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: Implications and policy recommendations

COVID-19 and mental health: a review of the existing literature

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Psychometric validation of the Bangla Fear of COVID-19 Scale: confirmatory factor analysis and Rasch analysis

Adaptation of the Fear of COVID-19 Scale: its association with psychological distress and life satisfaction in Turkey

Validation and psychometric evaluation of the Italian version of the Fear of COVID-19 Scale

A brief measure for assessing Generalized Anxiety Disorder: the GAD-7

Translation and validation of body image instruments: challenges, good practice guidelines, and reporting recommendations for test adaptation

Sensitivity to change and minimal clinically important difference of the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7)

WHO Director General's Opening Remarks at the Media Briefing on COVID-19

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