Validity and reliability of the fear of COVID-19 scale (FCV-19) in Turkish pregnant women

Abstract

AimThe emergence of coronavirus disease 2019 (COVID-19) has not only create international concern, but also caused panic, fear, and an increase in mental health problems among individuals. Fear of COVID-19 Scale (FCV-19S), developed by Ahorsu, was previously reported as a valid psychometric instrument for the assessment of COVID-19 fear among individuals. Validation of the scale among other high-risk groups like pregnant women may help obstetricians develop better coping skills during the pandemic.MethodsThis cross-sectional methodological study included 277 pregnant women admitted for routine follow-up at the outpatient obstetrics clinic of Liv Ankara Hospital, Turkey. Participants were asked to complete the Turkish version of the Hospital Anxiety and Depression Scale (HADS) and FCV-19S. Statistical analysis was performed using SPSS 25 software.ResultsThe mean FCV-19S score was 19.2±5.7 (range: 7-35). Cronbach’s alpha for internal consistency evaluating the reliability of FCV-19S, was 0.857, revealing a satisfactory internal consistency. According to the correlation matrix analysis, all items of FCV-19S showed positive and strong correlations with total FCV-19S scores (p<0.001), and positive and moderate correlations with HADS scores (p<0.001).ConclusionTurkish version of FCV-19S is a valid and reliable clinical tool to assess the anxiety of pregnant women during the COVID-19 pandemic in Turkey.

Keywords

Introduction

The emergence of coronavirus disease 2019 (COVID-19) has led to a global health burden worldwide. The World Health Organization (WHO) announced COVID-19 as one of the most critical public health emergencies of the 21st century, considering the mortality and morbidity of the disease itself. The rapid spread and high contagiousness of the disease have not only created international concern but also caused panic, fear, and an increase in mental health problems among individuals. As of the second year of the WHO announcement, more than 460 million cases were diagnosed, and more than 6 million people died due to COVID-19 (available from: https://covid19.who.int/). In recent research on the COVID-19 pandemic, it has been well documented that the disease is responsible for precipitating several psychological and mental disorders.¹
Since the beginning of the pandemic, many preventive measures have been implemented. Countries limited social life, shifted to home-based work, and applied lockdowns and other strict quarantine measures. However, uncertainties regarding prognosis, rapid deterioration of health status in infected individuals, myths, and misinformation caused high anxiety and depression. High-risk groups characterized by high clinical vulnerability for severity and mortality by COVID-19—including patients diagnosed with diabetes mellitus, hypertension, and cardiovascular disease—have been another public health concern for governments.² Especially after the emergence of the Delta variant in June 2021, pregnant women came to be considered another high-risk group. Based on data from previous severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV) epidemics, it has been alleged that COVID-19 may be associated with high incidences of spontaneous miscarriage, preterm delivery, and intrauterine growth restriction as well.^3-4
It is well known that stress and anxiety during pregnancy can trigger a cascade of events that may cause serious mortality and morbidity. Despite the lack of reliable information on pregnancy complications during coronavirus infection, COVID-19 is clearly an influential factor in the mental health of pregnant women.⁵ Hence, accurate and precise evaluation of COVID-19 anxiety during pregnancy has become essential for preventing adverse maternal and fetal outcomes. It has been previously reported that the Fear of COVID-19 Scale (FCV-19S), developed by Ahorsu et al., is a valid psychometric instrument for assessing COVID-19 fear among individuals.⁶
In this study, we aimed to evaluate the reliability of FCV-19S’s validation for use in Turkey among pregnant women.

Materials and Methods

This cross-sectional methodological study was conducted at the Obstetrics and Gynecology Department of Liv Ankara Hospital affiliated with Yuksek Ihtisas University in Ankara, Turkey. Pregnant women admitted for routine follow-up visits at outpatient clinics were informed about the study, and written informed consent was obtained from those who agreed to participate. Inclusion criteria were age ≥ 18 years and the ability to understand written and spoken Turkish.
Initially, participants completed a sheet with basic socio-demographic information. Afterwards, they completed the Turkish version of the Hospital Anxiety and Depression Scale (HADS) and the Fear of COVID-19 Scale (FCV-19S), both translated by Turkish researchers.
The HADS scale contains 14 items and consists of 2 subscales: anxiety and depression. It has long been proven to be a reliable clinical tool for assessing depression and anxiety.⁷
The FCV-19S is a seven-item scale assessing fear of a pandemic situation.⁶ Within the scope of the primary hypothesis, data collected using HADS and FCV-19S were subjected to validity-reliability analysis. Within the secondary hypothesis, associations between scale scores and demographic/clinical characteristics were analyzed.
The sample size was determined according to multivariate analyses described by Tabachnik and Fidell,⁸ assuming a type I error of 5% and a power of 90%. Consequently, n = 250 pregnant women were recruited, accounting for a 10% non-response and/or data loss rate.
Internal consistency was evaluated using Cronbach’s alpha coefficient. Pearson’s correlation analysis was used for correlations between numerical data. Exploratory factor analysis (EFA) was performed to examine the underlying structure of the tests. Statistical analyses were conducted with SPSS 25 software.
The study protocol was approved by the Ethics Committee of Yuksek Ihtisas University (Date: 11.11.2020; Approval No: 2020/13/02).Ethical ApprovalEthics Committee approval for the study was obtained.

Results

A total of n = 277 pregnant women were included in the study. The basal demographic characteristics of patients are presented in Table 1.
The mean FCV-19S score was 19.2 ± 5.7 (range: 7–35) (Table 2). The distribution of responses to FCV-19S items and the distribution of total FCV-19S scores are shown in Figure 1.
The reliability of the FCV-19S was evaluated using Cronbach’s alpha for internal consistency, which was 0.857, indicating satisfactory reliability. Reliability was also analyzed using item–total score correlations for FCV-19S and correlations with HADS anxiety and depression scores. The correlation matrix is presented in Table 3.
All items of FCV-19S showed positive and strong correlations with total FCV-19S scores, and positive moderate correlations with HADS anxiety and depression scores.
The psychometric characteristics of the FCV-19S regarding construct validity were evaluated using exploratory factor analysis (EFA) with principal component analysis. The Kaiser-Meyer-Olkin statistic was 0.83, suggesting adequacy of sampling, and Bartlett’s test was statistically significant (p<0.001), indicating that the data matrix was suitable for analysis.
The EFA revealed a two-factor structure. The first factor included the initial item of FCV-19S that questioned whether the patient had COVID fear, and the second factor included the remaining six items (Table 3). This two-factor structure explained 73.1% of the total variance in the sample population.

Discussion

The results of our study show that the fear of COVID-19 scale is a valid and reliable clinical tool to assess the anxiety of pregnant women during the COVID-19 pandemic in Turkey.
Previous studies have shown that the psychometric properties of this 7-item scale can adequately and consistently evaluate COVID-19 fear among individuals. The validity and reliability studies of the scale for use in Arabia, Israel, Italy, and Eastern European countries were completed in a short period after the original study was published, and in a recent large-scale study, the Italian version of the scale was also reported to be a reliable and valid tool for assessing the severity of fear of COVID-19.⁹
Although the detrimental effects of quarantine measures on the mental health of individuals have been well documented,¹⁰ there are no properly defined preventive strategies for stress and anxiety related to COVID-19. FCV-19S may help foresee excessive fear related to the disease and contribute to stress control. Previous studies have pointed out the necessity of the scale in terms of maintaining prevention or intervention programs.^11-12-13-14
The validity of the Turkish version of the test among pregnant women, ascertained using the HADS test, enables the early prediction of mental instability in pregnant women accompanying emotional instability related to physiological changes of pregnancy during the pandemic.
In another recent study among medical students in Vietnam, the fear of COVID-19 scale was once again confirmed as being a valid and reliable tool to screen for fear during the pandemic. A remarkable finding of the study was that easy access to medical support significantly decreased the severity of fear according to the scale.¹⁵
Considering the correlation between high scores of FCV-19S and HADS, it can also be concluded that higher overall scores on the FCV-19S indicate a more severe fear of COVID-19 among pregnant women.
The current study has some limitations. Lack of information among patients about coexisting mood disorders or formal diagnoses is the main limitation. Hence, fear may exacerbate the symptoms of those with pre-existing psychiatric disorders, and we cannot exclude the role of underlying pathology. The subjectivity of fear may have also interfered with the consistency of the study.

Conclusion

Awareness of COVID-19 fear is crucial for developing better-coping skills during the pandemic. If stress is properly managed, the joy and happiness of pregnancy may balance emotional instability and hence prevent adverse fetal outcomes related to maternal stress derived from fear of COVID-19. Therefore, enlightenment of pregnant women about the risks, prevention strategies, and developing skills for stress management is essential. To the best of our knowledge, this is the first study assessing the fear of COVID-19 during pregnancy. Large scaled studies are required for the assessment of the psychological burden caused by COVID-19 fear among pregnant women.

References

1. Shrivastava SR, Shrivastava PS. COVID-19 and impairment of mental health: public health perspective. Afr Health Sci. 2021;21(4):1527-1532.
   PubMed · Google Scholar
2. Figliozzi S, Masci PG, Ahmadi N, et al. Predictors of adverse prognosis in COVID-19: a systematic review and meta-analysis. Eur J Clin Invest. 2020;50(10):e13362. doi:10.1111/eci.13362
   Article · PubMed · Google Scholar
3. Wong SF, Chow KM, Leung TN, et al. Pregnancy and perinatal outcomes of women with severe acute respiratory syndrome. Am J Obstet Gynecol. 2004;191(1):292-297. doi:10.1016/j.ajog.2003.11.019
   Article · PubMed · Google Scholar
4. Alfaraj SH, Al-Tawfiq JA, Memish ZA. Middle East respiratory syndrome coronavirus infection during pregnancy: report of 2 cases and review of the literature. J Microbiol Immunol Infect. 2019;52(3):501-503. doi:10.1016/j.jmii.2018.04.005
   Article · PubMed · Google Scholar
5. Suzumori N, Goto S, Sugiura-Ogasawara M. Management strategy of pregnant women during COVID-19 pandemic. Aust N Z J Obstet Gynaecol. 2020;60(4):E9-E10. doi:10.1111/ajo.13202
   Article · PubMed · Google Scholar
6. Ahorsu DK, Lin CY, Imani V, Saffari M, Griffiths MD, Pakpour AH. The Fear of COVID-19 Scale: development and initial validation. Int J Ment Health Addict. 2022;20(3):1537-1545. doi:10.1007/s11469-020-00270-8
   Article · PubMed · Google Scholar
7. Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 1983;67(6):361-370. doi:10.1111/j.1600-0447.1983.tb09716.x
   Article · PubMed · Google Scholar
8. Tabachnick BG, Fidell LS, eds. Using Multivariate Statistics. 7th ed. Pearson; 2019:476-515.
   PubMed · Google Scholar
9. Soraci P, Ferrari A, Abbiati FA, et al. Validation and psychometric evaluation of the Italian version of the Fear of COVID-19 Scale. Int J Ment Health Addict. 2022;20(4):1913-1922. doi:10.1007/s11469-020-00277-1
   Article · PubMed · Google Scholar
10. Barbisch D, Koenig KL, Shih FY. Is there a case for quarantine? Perspectives from SARS to Ebola. Disaster Med Public Health Prep. 2015;9(5):547-553. doi:10.1017/dmp.2015.38
    Article · PubMed · Google Scholar
11. Yang Z, Zhang Y, Xu H, et al. Generalized anxiety disorder among rural primary and middle school students during the outbreak of COVID-19: a multicenter study in three southern Chinese cities. BMC Public Health. 2023;23(1):327. doi:10.1186/s12889-023-15215-8
    Article · PubMed · Google Scholar
12. Pakpour AH, Griffiths MD. The fear of COVID-19 and its role in preventive behaviors. J Con Dis. 2020;2(1):58-63.
    PubMed · Google Scholar
13. Huizink AC, de Rooij SR. Prenatal stress and models explaining risk for psychopathology revisited: generic vulnerability and divergent pathways. Dev Psychopathol. 2018;30(3):1041-1062. doi:10.1017/s0954579418000354
    Article · PubMed · Google Scholar
14. Stein A, Pearson RM, Goodman SE, et al. Effects of perinatal mental disorders on the fetus and child. Lancet. 2014;384(9956):1800-1819. doi:10.1016/s0140-6736(14)61277-0
    Article · PubMed · Google Scholar
15. Nguyen HT, Do BN, Pham KM, et al. Fear of COVID-19 Scale: associations of its scores with health literacy and health-related behaviors among medical students. Int J Environ Res Public Health. 2020;17(11):4164. doi:10.3390/ijerph17114164
    Article · PubMed · Google Scholar

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