The validation of Corona Anxiety Questionnaire in Iranian Population

Background: Anxiety is an evolutionary mental status that alerts a person from possible dangers: inside or outside dangers. One of the external dangers that threaten global society these days is Corona's disease. It has reported since 2020 January in Iran and has killed more than 8000 people during 5 month. But someone are unaware of the importance and danger of Corona or they don't consider any reason to worry. The aim of this study was to design and standardize a special questionnaire for corona anxiety in the Iranian population. Because of it, with the help of 10 psychologists and psychiatrics found 8 scales and wrote 36 question. Questionnaire asked from 523 internet operators by porsline.ir all over Iran. Method: To assess the reliability, kappa statistic was calculated and for construct validity, exploratory factor analysis (EFA) with Varimax rotation and conrmatory factor analysis (CFA) were used. Convergent and discriminant validity was checked using Spearman correlation and for content validity index (CVR) was used. Result: Reliability for the most items was high. Questionnaire showed excellent convergent and discriminant validity except for social support subscale. The results of categorical conrmatory factor analysis supported the t of the eight-factor model of the Corona Anxiety Scales-36. Furthermore, the average of CVR was higher than acceptance level (0.62). Conclusion: The ndings showed that the corona anxiety questionnaire is a questionnaire with appropriate validity and reliability for use in anxiety related to the unknown corona disease.


Background
Anxiety is an evolutionary mental status that alerts a person from possible dangers (1). These dangers may be internal (psychological threats) or external (social threats), but anxiety does not have a speci c root and cause obviously, so it always manifests itself as anxiety and restlessness. While being rootless, it can be caused by environmental factors such as health and life risks, and the nervous pressure is often so deep and persistent that it can lead to the physical pains and physical disorders such as migraine headaches and stomach pain in addition to using the endocrine system (2,3). One of the external dangers that threaten global society these days is Corona's disease. Corona is the family of lung viruses that can kill a patient with u-like symptoms within a few days (4). By the advent of corona, all medical and governmental systems around the world have tried to control and prevent it.
However, hundreds of people suffer from the disease almost every day. At the same time, it has been determined that the level of predicting risk by individuals in different provinces is very different despite the numerous trips of the Iranian people to recreational and tourism areas. This means that some people are unaware of the importance and danger of Corona or they don't consider any reason to be worry. Currently, approximately 8.3% of Iranian people suffer from a variety of anxiety disorders (5), and this disorder is observed more among women and single people with poorer social support (6). Current anxiety questionnaires such as the Depression Anxiety Stress Scales (DASS) (7) and the Beck Anxiety Inventory (BAI) (8) and the General Health Questionnaire (GHQ) (9) measure the general anxieties and do not target the speci c anxiety of an acute and infectious disease. Therefore, the need for a questionnaire that can assess the psychological sensitivity of individuals in the general society about an acute and fatal infectious disease such as Covid19 can be useful in research that seeks to in uence the media and the truthfulness of individuals.
In addition to psychoanalysis of corona anxiety, this questionnaire can examine the anxiety of those diseases by replacing a few words and naming acute diseases instead of corona.

Methods
To determine the necessary scales for corona anxiety, 3 psychologists and psychiatrists were polled who have a background in the eld of psychology of chronic diseases. Su cient questions were designed for the available scales. Questions designed were evaluated by 10 psychologists and 10 normal individuals. After removing the repeated and less relevant questions, using the online random sampling method in the general population for each question, more than 10 people were considered for answering, and thus questions were asked from 523 computer users. Due to the release of Corona and the protection of sanitary privates, the questionnaire was uploaded on the website porsline.ir so that eager people can complete the questionnaire online.
Inclusion criteria: All Iranian people could participate in the survey without considering demographic information. Exclusion criteria: Questionnaires that were not fully lled out or that the researcher made it possible to accidentally ll out were removed.
SPSS 16 and MedCalc 14 were employed to perform the exploratory factor analysis and discriminant and convergent analysis; also, the Amos 23 software was used to perform the CFA analyses.
The reliability of the Corona Anxiety subscales was tested using the Cronbach's alpha coe cient. The coe cient values of greater than 0.7 was considered as satisfactory internal consistency. The exploratory factor analysis (EFA) with varimax rotation and con rmatory factor analysis (CFA) were used to determine the construct validity of the Corona Anxiety Scale. According to Kline (10), the value of 0.40 was used as a factor loading criterion in the exploratory factor analysis in the correlation matrix between the Corona Anxiety items and the eight hypothesized subscales. CFA was utilized to assess the relationship between a set of continuous latent variables and a number of observed variables (the items of the Corona Anxiety-36). In this research, we studied whether or not the assumed eight-factor model is a good model for data. A number of goodness-of-t indices were used for investigating the goodness of t of the model, including Tucker-Lewis index (TLI), comparative t index (CFI), and the root mean square error of approximation (RMSEA).Values of RMSEA ≤ 0.08, and CFI and TLI ≥ 0.90 determined an adequate model t (11).
Convergent and discriminant validity were assessed using Spearman correlation coe cient. The value of a coe cient should be at least 0.40 between a scale and its own item for convergent validity. Discriminant validity is supported whenever a correlation between an item and its hypothesized subscale is higher than its correlation with the other subscales. The correlation between an item and its own-subscale should be signi cantly higher than the correlations of that item to other subscales (12). Content validity index (CVR) was calculated based on the responses to the necessity of questions (n e ) and total number of people (N) with CVR= (n e -N/2)/ (N/2). According to Msyamboza (2005), for 10 professionals, the minimum required CVR for each item is 0.62 (13). The questions related to each of the questionnaire items are given in Table 1. A 36-item questionnaire and a 4-point Likert answer (1. Not at all; 2. Less; 3. To some extent; 4. Very much) examines the general understanding of the importance and degree of risk of Coron's disease, and it has 8 sub-scales 1) Sensitivity to cleaning; 2) New disorders in the Corona effect; Social sensitivity and touch; 4) Background of anxiety and psychological disorders; 5) Social support; 6) Sensitivity to provide individual responsibility; 7) Verbal avoidance of illness; 8) Sensitivity to religious beliefs and a total score of anxiety.

Results
Of all 523 responders, the median age was 36 (range 11 to 79 years) with a mean of 37.19 (SD = 12.7). The majority of responders were female (62.6%) with 35% having high school or less and 21% having obtained MD and PhD. They all lived in cities with only 3% having acquired symptoms of COVID-2019 and 5% having OCD history.  The result of the factor analysis with Varimax rotation to test the construct validity of the Corona Anxiety Scale is presented in Table 3. The proportions of variance explained by the rst eight factors are 53.75%. Only the items of 'History of obsessive disorder' in background of anxiety and psychological disorders subscale has a weak correlation (below 0.4) with its own domain. Nevertheless, the results of CFA supported the t of the eight-factor model with RMSEA = 0.055, CFI = 0.83, TLI = 0.8 for the Corona Anxiety Scale. In this table, the result of CVR were calculated for each item. Minimum and maximum CVR were 0.6 and 1, except for 'Obsession of exist Corona virus', 'obsession for sin', "sleeping disorder affected by Corona', 'intentions of suicide', 'social support for talk', and "Commitment to religion". Total CVR for the entire questionnaire (average of CVRs of all items) was 0.82, so in average CVR was higher than the acceptance level (0.62). The result of the convergent and discriminant validity for the Corona Anxiety Scale is presented in Table 4. These ndings show that the scaling success rates for convergent and discriminant validity are 100% for all domains except for social support subscale. In this subscale, the success rate for item convergent and discriminant validity of items are 80% (4/5) and 89% (31/35), respectively.

Discussion
The present study was conducted to construct Corona Anxiety Questionnaire and examining its validity and reliability. According to the results, this questionnaire is a valid tool among Iranian people with a desirable reliability number and excellent convergent and discriminant values. The results of exploratory factor analysis presents a document that this questionnaire has 8 dimensions: Sensitivity to Cleaning, New disorders in the corona effect, Social sensitivity and touch, Background of anxiety and psychological disorders, Social support, Sensitivity to provides individual responsibility, Verbal Avoidance of Illness, and Sensitivity to religious beliefs, which is also con rmed by CFA Factor Analysis (CFA). These 8 dimensions explain about half of the variance between variables.
According to the DSM-IV-TR classi cation, the category of anxiety disorders includes obsessive-compulsive disorder, panic attack, pervasive anxiety disorder, and post-traumatic stress disorder. This classi cation is based on the effect of anxiety on external behavior, such as hand washing or avoiding discussion about fear and anxiety (14). Relying on this type of classi cation, the present questionnaire also included obsessive-compulsive disorder as anxiety disorders, and in addition to past and new anxiety symptoms due to corona, it has paid attention to past and new obsessive-compulsive symptoms.
The components extracted in the Sensitivity to Cleaning dimension include Sensitivity to behavioral symptoms, Obsessive to wash, Sensitivity to physical symptoms, Physically avoid people, Run away from people because of fear of illness The DSM-IV-TR refers to the classi cation of a variety of anxiety disorders as anxiety disorders caused by general medical illness. The sub-scale of new disorders in the corona effect is considered based on this division (14).
The components extracted in the Social sensitivity and touch dimension include Obsessive about awareness, Obsessive about awareness, Distrust to people, Sensitivity about touch, Run away from people because of the fear of poverty and Obsessive to wash. This scale in the classi cation of delusional disorders is a subset of the bite and injury delusion. DSM-IV-TR divides this disorder into belief in injury and conspiracy by strangers by others (14).
The components extracted in the Background dimension of anxiety and psychological disorders include History of healthy obsessive, History of mental disorders, History of Psychosomatic and Disbelief about obsession. In addition to the fact that DSM-IV-TR considers a signi cant amount of anxiety disorders as a result of people's pathology backgrounds (14), the MMPI questionnaire (17)  Research has shown that religious beliefs can be a powerful preventative against anxiety disorders and have a better prognosis for sufferers (18). Therefore, the level of trust in God and religious rites was included in this questionnaire. In this way, it can be found that the components of Corona Anxiety Questionnaire are in accordance with the components mentioned in the theoretical and experimental texts, and the ndings of the present study con rm its validity and reliability. But it's important to note that Cronbach's alpha is less than 0.05 in three dimensions, Background of Anxiety and Psychological Disorders, Social Support, and Verbal Avoidance of Illness. Furthermore, Question 17, entitled History of healthy obsessive with a correlation of 0.31, which is less than the appropriate standard of 0.4, is in its dimension (Background of anxiety and psychological disorders). Finally, this questionnaire was conducted only on Iranian people, and therefore its generalization to individuals in other countries requires further study.

Conclusion
Although several questionnaires have been already presented in the eld of anxiety in psychology, it is necessary to design a special questionnaire about Corona disease which is a new and unknown disease. In general, the ndings show that the corona anxiety questionnaire is a questionnaire with appropriate validity and reliability for use in anxiety related to the unknown corona disease. Consent for publication "Not applicable" in this section.

Availability of data and materials
The datasets during and/or analysed during the current study available from the corresponding author on reasonable request.

Competing interests
There is no competing interests.

Funding
This study was nancially supported by Vice-Chancellor for Research of Shiraz University of Medical Sciences. The supporting organization did not have any role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Authors' contributions
MM have involved in the study concept and design, acquisition of data, drafting the manuscript, administrative, statistical analysis, technical and study supervision and nal proof of the manuscript.
MRH have involved in the study concept and design, acquisition of data, drafting the manuscript, administrative, statistical analysis, technical and study supervision and nal proof of the manuscript.
MF have involved in statistical analysis and interpretation of the data, critical revision of the manuscript for intellectual content and nal proof of the manuscript.
HJ have involved in Conceptual Design and technical and study supervision, statically analysis and nal proof of the manuscript.