DOI: https://doi.org/10.21203/rs.3.rs-23281/v1
Background
Anxiety among women in the perinatal period is common. Assessing the severity of perinatal anxiety will help monitor the progress of the patient through the stages of anxiety and facilitated the treatment. This study assesses the validity and reliability of the “Perinatal Anxiety Screening Scale” (PASS) in the Arabic language.
Methods
The PASS was translated into Arabic. 217 women in the antenatal and postnatal phase participated (92 antenatal and 125 postnatal) answered to PASS, GHQ12, and EPDS. Content validity, factor analysis, internal consistency, and test retest reliability were assessed.
Results
Content Validity Index (CVI) and Content Validity Ratio (CVR) were .88 and 0.79; respectively. The scale loaded on four components: acute anxiety, social anxiety, and dissociation; specific fears and trauma; general anxiety and adjustment; and perfectionism and control. Cronbach’s Alpha value for the scale was 0.78 and test retest correlation coefficient was 0.94. PASS significantly correlated with EPDS (rho = 0.46) and GHQ12(rho = 0.58).
Conclusion
The Arabic translated version of the PASS showed reasonably adequate validity and reliability and can be used to screen for anxiety disorder among women in the perinatal phase.
Maternal health can be negatively impacted by untreated anxiety [1–3]. Anxiety can also negatively affect the behavioral development, emotional and cognitive status of the child [4], and the mother-infant relationship [5, 6]. For this reason, the detection of problematic anxiety via the use of an effective screening tool may be important in screening for risk of problematic anxiety, prevention, early intervention, and treatment in the field of perinatal mental health.
Knowing the severity of anxiety is important to guide the treatment for the patient [6]. Also, continuous monitoring of response to psychological and/or pharmacological treatment is essential to evaluate the effectiveness of the plan of care [7]. Depending on the severity of their symptoms, women can be assigned to maternity and childcare services, counseling services, psychosocial therapy, or to psychiatric hospitalization in severe cases [6].
A validated tool that assesses the severity of perinatal and postnatal anxiety will help monitor the progress of the patient through the stages of anxiety and facilitated the adjustment of the treatment approach as required [8, 9].
There are no Available scales in the Arabic language to assess antenatal anxiety and classify patients according to the stages of severity of symptoms. The Depression, Anxiety and Stress Scale (DASS-21) [10] have been validated in Arabic and is used among the general population. However, this scale measures are limited in classifying the severity of anxiety in the perinatal period because it has not been validated in perinatal samples and failed to include measures of anxiety related to pregnancy [11]. The Edinburgh Postnatal Depression Scale (EPDS) [6] has also been validated in Arabic and is a self-administered scales that screens for depression and classifies women at risk for anxiety if they score over a pre-established cut-off score [12]; however, the scale does not classify the severity of anxiety according to pre-established severity ranges. The EPDS is lacking in psychometric sensitivity for screening for anxiety disorders [13](13).
The Perinatal Anxiety Screening Scale (PASS) is a 31-item self-administered scale to screen for anxiety in antenatal and postnatal women [14]. The scale includes measures such as fear of birth or fear that harm will come to the baby. It has a four-factor structure that assesses symptoms of acute anxiety; worry and fear; perfectionism, control, and trauma; and social anxiety [14]. A cut-off score of 26 was established to identify 68% of women at risk of an anxiety disorder [14].
The main aim of this study is to validate the Perinatal Anxiety Scale (PASS) in the Arabic language to increase its usefulness as a screening tool for tracking and treatment progress for problematic antenatal and postnatal anxiety. After validation, it is recommended to test the properties of the valid and reliable scale among a sample of Arabic speaking antenatal and postnatal women.
Overall 252 women were consented for this study. Thirty five of them were consented for the initial piloting phase and were not included in the final sample size, and the remaining 217 perinatal (92 in antenatal phase and 125 in postnatal phase) were enrolled in the validity and reliability study of the PASS scale (recruitment of one survey participants per one item in the survey to be validated; 1:7 ratio for 31 items). Women were recruited from the obstetrics/gynecology and pediatric clinics at King Fahad National Guard Hospital in Riyadh. The chosen clinics provide care for women and their infants from different socioeconomic backgrounds. The clinic serves personnel from the military, their families, in addition to employees affiliated with the hospital and a large University system and their dependents. Women were approached and asked to participate in the study (after initial pilot phase 233 were asked to participate, 16 refused to participate yielding a 93% response rate). Illiterate women and those with a disability that prevents them from participating in the study were excluded. Written consent was obtained from all participants. Data collection continued for a period of 3 month.
The first step of the validation process was the standard "forward-backward" procedure to translate the original version of the PASS questionnaire from English into classical Arabic by two professional translators and subsequently it was back translated into English. The translated scale was reviewed by two bilingual psychologists for appropriateness of the language and cultural adaptation. The reviewed translated version of the scale was back translated and checked for consistency. Content validity was assessed by presenting the translated instrument to a group of experts (an obstetrics/gynecology physician, two psychologists, and two nurses and a health educator from the maternity clinic). The group evaluated the relevance and cultural appropriateness of each item of the scale and Content Validity Ratio (CVR) and Content Validity Index (CVI) were generated. The translated Arabic version of the PASS questionnaire was piloted in a sample of new mothers (N = 20) to ensure clarity of all terms. Finally, the Arabic version and the English version of the tool were administered consecutively within 15 minutes to a group 15 bilingual female office employees. Correlation of the English and Arabic version was calculated using the Spearman correlation coefficient (rho) and a value of 0.78 was documented. Additionally, the convergent validity of the PASS was assessed by concurrently administering the Arabic versions of the Edinburgh Postpartum Depression Scale (EPDS-10) and the General Health Questionnaire (GHQ-12) to study participants. Both the EPDS-10 and the GHQ-12 are valid and reliable scales in the Arabic language previously used to screen for depression and psychological distress in the prenatal and postpartum period [15, 16].
Participants were also asked to complete a demographic questionnaire (age, gender, marital status, employment status, level of education, and income), and questions related to adverse life events experienced within the last year (divorce in the family, problems at work or university, death in the family, illness in the family, financial problems, other personal problems, or health problems related to pregnancy or delivery). We anticipated that a positive correlation between these negative life events and the PASS will add to the validity of the scale. Moreover, the factor structure of the questionnaire was performed using principal component analysis (PCA) with Varimax rotation. The reliability of the scale was checked via internal consistency and test retest reliability. Cronbach’s alpha coefficient was reported for internal consistency (alpha ≥ 0.70 was considered acceptable) ([17].Test-retest reliability was conducted (N = 30) within one week interval and a correlation coefficient was obtained.
The mean age of 217 participants was 28.89 years (range between 19 and 44) with a standard deviation of 7.07 years. Most of the sample (70.51%) reported having a college degree. The majority (58.06%) did not work and 56.28% reported that their income was adequate for their lifestyle; an income of less than 10,000 Saudi Riyals (SAR) was reported by approximately half (47.69%) of the sample. Using the recommended cut-off values for the PASS scale [14] of 0–20 (minimal anxiety), 21–41 (moderate anxiety), and above 41 (severe anxiety), 34.10% of the participating women reported moderate anxiety and 47.0% reported severe anxiety. Participants’ characteristics are presented in Table1.
| Characteristics | N | % |
|---|---|---|
| Age (µ = 28.89 ± 7.07) | ||
| 18–25 | 51 | 23.50 |
| 26–34 | 126 | 58.06 |
| ≥35 | 40 | 18.30 |
| Marital Status | ||
| Married | 214 | 98.62 |
| Divorced/Separated/Widowed | 3 | 1.38 |
| Level of Education | ||
| Highschool or less | 64 | 29.49 |
| College or more | 153 | 70.51 |
| Employment Status | ||
| Unemployed | 127 | 58.52 |
| Employed/Student | 90 | 41.47 |
| Income (SR)* | ||
| < 10,000 | 104 | 47.46 |
| ≥10,000 | 113 | 52.07 |
| Pregnancy Stage | ||
| Antenatal | 92 | 42.40 |
| Postnatal | 125 | 5760 |
| Level of Anxiety (PASS) | ||
| Low | 41 | 18.89 |
| Moderate | 74 | 34.10 |
| High | 102 | 47.0 |
| *SR = Saudi Riyals | ||
Frequency of responses to each of the questions of the Arabic version of the PASS scale are displayed in Table 2. The mean average score for the Arabic version of the PASS scale was 41.01(SD = 20.55) (range: 0 to 93). The mean EPDS-10 score was 17.57 (SD = 4.32) (range: from 0 to 30) with 82.40% of the surveyed women scoring above 13 for depression (indicative of depression illness) (cox). Additionally, the mean score for GHQ-12 was 10.81(SD = 7.30) (range: 0 to 36) and 36.87% of participants exhibited an above 12 score (indicative of mental disorder and psychological distress) [18]. Mean scores for the three scales are presented in Table 3.
| PASS Items | Not at all N (%) | Sometimes N (%) | Often N (%) | Almost Always N (%) |
|---|---|---|---|---|
| Total anxiety score (µ = 41.02; SD = 20.55) | ||||
| 1.Worry about baby/pregnancy | 69 (31.80) | 79 (36.41) | 46 (21.20) | 23 (10.63) |
| 2.Fear that harm will come to the baby | 78 (35.94) | 78 (35.94) | 40 (18.43) | 21 (9.68) |
| 3.A sense of dread that something will come to the baby | 56 (25.81) | 65 (29.91) | 32 (14.75) | 64 (29.49) |
| 4.Worry about many things | 55 (25.35) | 88 (40.55) | 41 (18.89) | 33 (15.21) |
| 5.Worry about the future | 56 (25.81) | 62 (28.57) | 27 (12.44) | 72 (33.18) |
| 6.Feeling overwhelmed | 35 (15.67) | 5 (23.50) | 33 (15.21) | 99 (45.62) |
| 7.Really strong fears about things (needles, blood, birth, pain) | 45 (20.74) | 72 (33.18) | 53 (24.2) | 47 (21.66) |
| 8.Sudden rush of extreme fear or discomfort | 30 (13.82) | 59 (27.19) | 46 (21.20) | 82 (37.79) |
| 9.Repetitive thoughts that are difficult to stop or control | 44 (20.28) | 70 (32.26) | 38 (17.51) | 65 (29.95) |
| 10.Difficulty sleeping even when I have the chance to sleep | 33 (15.21) | 72 (33.18) | 42 (19.35) | 70 (32.26) |
| 11. Having to do things in a certain way or order | 35 (16.93) | 78 (35.94) | 52 (23.96) | 52 (23.96) |
| 12.Wanting things to be perfect | 68 (31.34) | 53 (24.24) | 51 (23.50) | 45 (20.74) |
| 13.Needing to be in control of things | 57(26.27) | 65 (29.95) | 50 (23.04) | 45 (20.74) |
| 14.Difficulty stopping checking things over and over | 42 (19.35) | 73 (33.64) | 36 (16.39) | 66 (30.41) |
| 15.Feeling jumpy or easily startled | 33 15.21) | 58 (26.73) | 42 (19.35) | 84 (38.71) |
| 16.Concerns about repeated thoughts | 39 (17.97) | 77 (35.48) | 38 (17.51) | 63 (29.0) |
| 17. Being on guard or needing to do watch out for things | 60 (27.65) | 89 (41.01) | 32 (14.75) | 36 (16.59) |
| 18.Upset about repeated memories, dreams, or nightmares | 40 (18.43) | 61 (28.11) | 30 (13.82) | 86 (39.63) |
| 19.Worry that I will embarrass myself in front of others | 34 (15.67) | 58 (26.73) | 34 (15.67) | 91 (41.94) |
| 20.Fear that others will judge me negatively | 36 (16.59) | 58 (26.73) | 28 (12.90) | 95 (43.78) |
| 21.Feeling really uneasy in crowds | 31 (14.29) | 46 (21.20) | 29 (13.36) | 111 (51.15) |
| 22.Avoiding social activities because I might be nervous | 26 (11.98) | 43(19.82) | 27 (12.44) | 121 (55.76) |
| 23. Avoiding things which concern me | 53 (24.24) | 59 (27.19) | 44 (20.28) | 61 (28.11) |
| 24.Feeling detached like watching yourself in a movie | 28 (12.90) | 32 (14.75) | 14 (6.45) | 143 (65.90) |
| 25.Loosing track of time and can’t remember what happened | 31 (14.29) | 54 (24.88) | 25 (11.52) | 107 (49.31) |
| 26.Difficulty adjusting for recent changes | 34 (15.67) | 49 (22.58) | 33 (15.21) | 101 (46.54) |
| 27.Anxiety getting in the way of being able to do things | 32 (14.75) | 79 (36.41) | 37 (17.05) | 69 (31.80) |
| 28.Racing thoughts making it hard to concentrate | 33 (15.21) | 68 (1.34) | 43 (19.82) | 73 (33.64) |
| 29.Fear of losing control | 36 (16.59) | 59 (27.19) | 34 (15.67) | 88 (40.55) |
| 30.Feeling panicky | 26 (11.98) | 45 (20.74) | 26 (11.98) | 120 (55.30) |
| 31.Feeling agitated | 25 (11.52) | 37 (17.05) | 27 (12.44) | 128 (58.99) |
| Scale | Median | Mean (SD) | Range | Spearman’s Rho (p-value) |
|---|---|---|---|---|
| PASS | 39 | 41.02(20.55) | 3–97 | - |
| EPDS-10 | 18 | 17.57 (4.32) | 5–26 | 0.46 (< 0.001) |
| GHQ-12 | 9 | 10.8 (7.30) | 0–33 | 0.58 (< 0.001) |
| Adverse life events | 6 | 6.7(5.4) | 0–19 | 0.28 (0.003) |
| PASS Items | Factor 1 | Factor 2 | Factor 3 | Factor 4 |
|---|---|---|---|---|
| Factor 1: Acute anxiety, Social Anxiety, and Dissociation | ||||
| 8.Sudden rush of extreme fear or discomfort | 0.55 | |||
| 15.Feeling jumpy or easily startled | 0.64 | |||
| 19.Worry that I will embarrass myself in front of others | 0.64 | |||
| 20.Fear that others will judge me negatively | 0.55 | |||
| 21.Feeling really uneasy in crowds | 0.73 | |||
| 22.Avoiding social activities because I might be nervous | 0.65 | |||
| 24.Feeling detached like watching yourself in a movie | 0.70 | |||
| 25.Loosing track of time and can’t remember what happened | 0.59 | |||
| 23. Avoiding things which concern me | 0.70 | |||
| 28.Racing thoughts making it hard to concentrate | 0.51 | |||
| 29.Fear of losing control | 0.62 | |||
| 30.Feeling panicky | 0.78 | |||
| 31.Feeling agitated | 0.82 | |||
| Factor 2: Specific Fears, and trauma | ||||
| 1.Worry about baby/pregnancy | 0.59 | |||
| 2.Fear that harm will come to the baby | 0.72 | |||
| 3.A sense of dread that something will come to the baby | 0.62 | |||
| 4.Worry about many things | 0.68 | |||
| 5.Worry about the future | 0.40 | |||
| 7.Really strong fears about things (needles, blood, birth, pain) | 0.44 | |||
| 9.Repetitive thoughts that are difficult to stop or control | 0.54 | |||
| 10.Difficulty sleeping even when I have the chance to sleep | 0.53 | |||
| 16.Concerns about repeated thoughts | 0.52 | |||
| 18.Upset about repeated memories, dreams, or nightmares | 0.49 | |||
| Factor 3: General Anxiety and Adjustment | ||||
| 6.Feeling overwhelmed | 0.47 | |||
| 17. Being on guard or needing to watch out for things | 0.62 | |||
| 26.Difficulty adjusting for recent changes | 0.72 | |||
| 27.Anxiety getting in the way of being able to do things | 0.51 | |||
| Factor 4: Perfectionism and Control | ||||
| 11. Having to do things in a certain way or order | 0.44 | |||
| 12.Wanting things to be perfect | 0.76 | |||
| 13.Needing to be control of things | 0.66 | |||
| 14.Difficulty stopping checking things over and over | 0.57 | |||
| Variance (%) (total: 54.53%) | 37.12 | 7.51 | 5.20 | 4.11 |
Internal consistency using Cronbach’s alpha coefficient as a measure of reliability of the Arabic version of the PASS questionnaire was found to be 0.94 for the whole sample indicating very satisfactory results. It was 0.83, 0.80, 0.86, and 0.90 for the four sections of the scale. The results of the test-retest reliability of the Arabic version of the PASS tool showed to be acceptable with a correlation coefficient of 0.78.
Validity of the instrument was assessed using convergent validity. The correlations between the Arabic version of PASS, the Arabic version of the EPDS-10, the Arabic version of the GHQ-12, and the score of the stressful life events within the last 12 months were significantly positive (Spearman’s rho = 0.46; p < 0.001, Spearman’s rho = 0.58; p < 0.001, and Spearman’s rho = 0.28; p = 0.003; respectively) indicating that those who had perinatal anxiety showed higher levels of depression and higher levels of psychological disorders (Table 3).
Results of the content validity results from the expert panel displayed a mean Content Validity Ratio (CVR) of 0.79 and a mean Content Validity Index (CVI) of 0.88.
In order to confirm the structure of the Arabic version of the instrument and demonstrate its construct validity and similarity to the English version, the Principal Component Method for factor analysis with varimax rotation was applied using the original four factor structure of the instrument. The four factors jointly accounted for 54.53% of the total detected variance. Factor 1 (acute anxiety, social anxiety, and dissociation) accounts for 37.12% of the total variance, Factor 2 (specific fears and trauma) 7.51%, Factor 3 (general anxiety and adjustment) 5.20%, and factor 4 (perfectionism and control) 4.11%.
This is the first study conducted to evaluate the validity and reliability of the Arabic Perinatal Anxiety Scale. This study showed that the Arabic version of the PASS is valid and reliable for use in the Arabic speaking populations and have good psychometric properties. Women who participated in this validation study were in the antenatal and postnatal phase, reflecting the suitability of the scale for both phases. Also, participants were from different age groups and different socioeconomic status.
The reliability coefficient was assessed and the Arabic version of PASS, similarly to the original English version of the scale (0.95) [14]and the Turkish version of the scale (0.96) [19], demonstrated high reliability (0.94). The test retest reliability of 0.78 was acceptable and comparable to the test retest reliability of the original scale of 0.74 [14].
The factor analysis was conducted with retaining the four components structure of the original version of the scale. Similarly, to the original English version [14] and the Turkish version[19] of the PASS, the questions loaded on the four factors; however, the actual distribution of the questions for the Arabic version of the PASS varied across the four components. The original scale factor structure were “acute anxiety and adjustment” for factor 1 (constructs related to panic disorder, dissociative disorder, and adjustment difficulties), “general worry and specific fear” for factor 2 (constructs related general anxiety disorder and phobia), “perfectionism, control and trauma” for factor 3 (constructs related to obsessive compulsive disorder and posttraumatic stress disorder), and “social anxiety” for factor 4 (constructs related to social anxiety) [14]. For the Arabic PASS, factor 1 included acute anxiety, social anxiety, and dissociation; factor 2 included specific fears and trauma; factor 3 included general anxiety and adjustments; and factor 4 included perfectionism and control. Actually, these results of factor analysis are similar to those obtained for the Turkish version of the scale on factor 4 (perfectionism and control) and partially for the other three factors [19]. These changes in the structure of components distribution for the scale may reflect the cultural and linguistic adaptation of the scale to the Arabic speaking population.
As hypothesized, the Arabic PASS had positive significant associations with previously validated Arabic versions of the EPDS-10 and GHQ-12. It is not surprising that the PASS correlated positively with the EPDS since anxiety and depression are known to occur concurrently in more than 50% of the time [20]. The results showed that more than 82.40% had depression illness among this group and 34.10% have severe anxiety. Results are indicative that some of the women in this group may suffer from anxiety with or without depression. The PASS can identify anxiety status regardless of the depression status among women in the antenatal and postnatal stage. Further studies are recommended for assessing the ability of the PASS to distinguish between those who have anxiety only or in combination with other psychological disorders among pregnant and postpartum women. There was also a positive, significant, but weaker, association between the PASS and the adverse life events. This existing low magnitude association may be due to the way people cope with adverse life events. For example, persons with good coping strategies may score low on the Arabic PASS even though their score for adverse life events is high. It is highly recommended to conduct further investigation regarding experienced life events and anxiety and the impact of coping strategies.
This study has some limitations. Participants were recruited from clinics in the Eastern part of Riyadh and the sample cannot be considered representative of the entire population of Riyadh or the Saudi population. However, formal Arabic was used to translate and validate the tool, making it comprehended and useful for all Arabic speaking nations.
This study provides the literature with an Arabic scale for assessing anxiety during the antenatal and postnatal period. The Arabic version of the PASS showed to be valid and reliable and can be used as a screening tool for anxiety among the Arabic speaking population.
We would like to thank the schools’ administrators’ that facilitated data collection.
No funding was available for this research
The datasets analysed during the study are available from the corresponding author on reasonable request and after approval of the concerned authorities in the organization.
HJ designed the study, analysed the data, wrote the first draft. TA collected the data and interpreted findings. HJ and TA reviewed and edited the final draft.
This research was approved by the Institutional Review Board at king Abdullah international Medical Research Centre. All participants signed a consent form prior to enrolment in the study.
Consent for publication of this study is granted by the authors.
The authors declare that they have no competing interests.