Development and validation of the Post-Pandemic Fear of Viral Disease scale and its relationship with general anxiety disorder: A cross-sectional survey from Pakistan

doi:10.21203/rs.3.rs-2577006/v1

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Development and validation of the Post-Pandemic Fear of Viral Disease scale and its relationship with general anxiety disorder: A cross-sectional survey from Pakistan

https://doi.org/10.21203/rs.3.rs-2577006/v1

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published 06 Sep, 2023

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Background: Given the worldwide reach of COVID-19, media coverage has amplified the psychological and social effects of this pandemic causing a widespread fear. Despite substantial research on the short-term psychological impact of COVID-19, its long-term consequences on mental health remain relatively unexplored. This research aims (i) to develop and validate a Post-Pandemic Fear of Viral Disease (PPFVD) scale and (ii) to investigate the presence of fear of viral diseases and its association with general anxiety disorder among the Pakistani population.

Methods: A cross-sectional online-based survey was conducted with 457 respondents in August and September 2022. We adopted the modified fear of coronavirus scale (FCV-19S) consisting of seven items and the Generalized Anxiety Disorder (GAD) questionnaire to measure anxiety disorder. Confirmatory factor analysis was applied using the maximum likelihood estimation method. Scale dimensions and item reliability were tested for their validity and goodness of fit. SPSS and AMOS were used for data management and analyses.

Results: All inter-item correlations were found to be significant and ranged between 0.30 and 0.70. The value of Cronbach’s alpha was 0.887, indicating good reliability. Corrected item-total correlations ranged between 0.632 and 0.754. Factor loadings ranged from 0.664 to 0.810, indicating a good internal consistency. Overall, these results clearly demonstrate that the one-factor solution model for PPFVD presents a good fit to the data. The composite reliability (CR=0.747) was also good.

Conclusions: The COVID-19 pandemic has negatively affected the mental health of people globally. This measurement scale can be trusted and used to test the PPFVD in the post-pandemic situation. Prospective research might validate this instrument in newly emerging scenarios and test it with diverse ethnic groups.

Post-Pandemic Fear

General Anxiety Disorder

virus

viral disease

Corona

SARS-CoV-2

validation

Pandemics and epidemics have been known to generate an environment of uncertainty – followed by panic, fear, and anxiety. The recent COVID-19 pandemic has posed large challenges to mental health and enforced anxiety [1]. It reformed the global lifestyle with an increased preference for virtual social interaction and individuals spending more time within their respective households (e.g., due to the ability and necessity to work from home). In addition, behavioral changes have been observed in terms of hygiene, saving money, and buying health insurance [2]. Unwanted and prolonged fear-based stay in houses and restricted mobility with constant fear of catching the virus has increased the likelihood of developing a post-pandemic fear of viral disease (PPFVD) and generalized anxiety disorder [3].

Previous research has confirmed that the COVID-19 pandemic evoked a range of reactions from both infected and uninfected people around the world [4]. Among the psychological effects of the pandemic are post-traumatic stress disorders, confusion, anxiety, frustration, fear of infection, insomnia, and a sense of helplessness [5]. Research from previous pandemics like Ebola revealed that the survivors experienced different multiple mental health issues such as obsession-compulsion, anxiety and paranoid ideation [6]. Similarly, research demonstrated that the Zika pandemic instilled anxiety in the public [7]. Empirical evidence confirmed the incidence of pandemic fear and anxiety since the outbreak of COVID-19 [8–10].

The COVID-19 pandemic has led to several social challenges and disruptions which presumably will remain for many years. While the enormous (financial) costs of the pandemic will only be known ex post, COVID-19 induced perpetual changes in human lives at individual, local/regional, and global levels. Many people lost their own lives or lives of their loved ones, many lost their employment or business, while many other were pauperized due to steady decline in world economy. Business at all levels had to suffer an irreparable loss. Strained economic conditions impacted all aspects of life which crumbled intimate relationships and family life. All of these challenges may be associated with psychological distress [4]. Individuals had to undergo extreme psychological distress that led to the awakening of fear. People showed fear of the viral infection, but also fear of touching other individuals, surfaces or things [11]. Fear is a distressing emotion, that occurs in the presence of a danger and is often accompanied by emotional distress and behavioral avoidance. Like any other event that touches human senses and is in our context of experience, we react to fear symbolically, by arbitrarily relating it to other objects and events through derived verbal relations [12]. Human beings react cognitively to every known event. Therefore, pandemics are not simply biological diseases confined to health specialists. Instead, they also influence individuals and society more generally through symbolic relations. Fear is not simply the evaluation of a threatening situation but the way we perceive our sense of impotence against a threat. According to Porcelli [13], fear involves a combination of subjective incompetence (“I am not able to cope with it.”), hopelessness (“I can do nothing about it.”), helplessness (“No one can help me.”), and catastrophizing (“Imminent death is coming closer.”).

Consistently, previous research has illustrated the emergence of fear as one of the behavioral responses to the pandemic on the one side and its implications for mental wellbeing, morbidity, and comorbidity on the other side. Improving our understanding of the experience of fear related to COVID-19 may have substantial clinical and societal implications, both during and after the pandemic [14]. In order to understand the anticipated fall outs of COVID-19, particularly the long-lasting effects of the pandemic on the mental health and wellbeing of the current generation need to be focused [15]. Understanding the dynamic post-pandemic risk factors is essential for policymakers and therapeutic interventions [16].

Already published literature on fear of disease demonstrates that fear of COVID-19 has also been studied in comparison to the fear of other infections [17]. Similarly, the pandemic fear was reported to have increased due to the misinformation on social media [18]. The COVID-19 pandemic has lasted for several years and brought significant changes to our daily lives [19], particularly induced by social restrictions, which in turn may have long-lasting impacts on the individual and collective life leading for example to sleep disturbance and anxiety. However, this situation causes a vicious circle [20]: Whether you suffered from social anxiety before or you have slowly developed social anxiety since being isolated and distanced from others, returning to post-pandemic “normal” life can seem more daunting than the onset of the pandemic itself.

These mental health effects are not limited to experiences during the pandemic, but they are long-lasting and can change the mental health of people for years to come. Although it is evident that the COVID-19 pandemic has a profound effect on mental health in the short-term, there is a lack of literature on how its psychological impact might translate to long-term negative outcomes in a post-pandemic world [10]. Furthermore, evidence suggests that some people have developed what has been termed COVID-19 stress syndrome, characterized by fear of infection, touching surfaces or objects that might be contaminated, xenophobia (fear that foreigners might be infected), and traumatic stress symptoms (e.g., COVID-19 related intrusive thoughts and nightmares) [21]. Previous studies (e.g., [22]) reported that fear is related to a higher level of health compliance but at the same time it also contributes to a higher level of distress and lower mental health in general.

In the light of the above-mentioned facts, there is a need for tools to assess the post-pandemic fear of viral disease. Thus, the present study has been conducted to investigate the aftershocks of COVID-19 with particular reference to fear produced. The major objective of this study was to develop and validate the Post-Pandemic Fear of Viral Disease Scale (PPFVD). We aimed to investigate the presence of fear of viral disease and its association with general anxiety disorder among Pakistani population.

Participants and procedures

We used a cross-sectional online-based survey to collect data from people living in Punjab, wich is the most populous province of Pakistan. Data was collected from August 20, 2022 to September 4, 2022. A hyperlink to the questionnaire was shared via social media platforms, such as Facebook, LinkedIn, and WhatsApp. The respondents were informed about the objectives of the study, and the anonymity of data. The respondents were not offered any incentive to participate in this study. Consent to participate was taken electronically. No survey could be submitted unless every question had been answered. In total, there were 457 respondents who successfully completed this survey.

Measures

In order to investigate the effect of socio-demographic variables on dear of viral diseases, the survey included questions related to age, gender, educational status, current place of residence, income and marital status.

Post-Pandemic Fear of Viral Diseases (PPFVD)

To measure post-pandemic fear of viral diseases, we adapted and modified the Fear of Coronavirus Scale (FCV-19S). The FCV-19S scale consists of 7 items (e.g., “It makes me uncomfortable to think about Corona” and “I cannot sleep because I’m worrying about getting Corona”) measured on a 5-point Likert scale [8]. The tool was modified for the post-pandemic context and used six items to measure post-pandemic fear of viral diseases. These items are

“I am most afraid of viral diseases after COVID-19 pandemic.”
“It makes me uncomfortable to think about viral diseases after COVID-19 pandemic.”
“My hands become clammy when I think about viral diseases after COVID-19 pandemic.”
“I am afraid of losing my life when I think about viral diseases after COVID-19 pandemic.”
“When I am watching news and stories about viral diseases, I become nervous or anxious.”
“My heart races or palpitates when I think about viral diseases after COVID-19 pandemic.”

These items were measured on a 4-point Likert Scale (from “great extent” to “not at all”).

Generalized Anxiety Disorder

We used seven items from the Generalized Anxiety Disorder (GAD-7) questionnaire [23] to measure anxiety disorders among respondents. The seven items used from the scale describe a number of the most salient diagnostic features of GAD (i.e., feeling nervous, anxious, or on edge and worrying too much about various things). Items are rated on a 4-point Likert-type scale (1 = “not at all” to 4 = “nearly every day”). The Cronbach’s alpha of this scale was 0.892, indicating good internal consistency.

Statistical analyses

IBM SPSS Statistics 21 and AMOS have been used for the statistical analyses. Descriptive statistics were used to report the sample characteristics. Measures of central tendency (mean and standard deviation) and measures of distribution (skewness and kurtosis) were calculated with respect to each item. To assess internal consistency of the PPFVD, we computed Cronbach’s alpha coefficient, inter-item correlations, and corrected item-total correlations. We also assessed concurrent validity of the PPFVD and predictive validity by predicting the variance of GAD through PPFVD. For confirmation of the unidimensional factor structure of the PPFVD, we conducted a confirmatory factor analysis using the maximum likelihood estimation (MLE) method. AMOS software was used for this purpose. Goodness of fit was assessed according to the following criteria: goodness of fit index (GFI < 0.90); adjusted goodness of fit index (AGFI < 0.90); comparative fit index (CFI > 0.90); and root mean square error of approximation (RMSEA ≤ 0.08).

Characteristics of participants

Of the 457 respondents, 294 (64.3%) were female and 163 (35.7%) male, with approximately 74.2% living in urban areas. The majority of participants (86.2%) belonged to the age group up to 30 years, followed by 12.0% who were aged between 31 and 45 years. Most of the respondents were either graduates (70.2%) or postgraduates (22.5%). The majority was unmarried (79.6%) (Table 1).

Table 1

Socio-demographic characteristics of sample (N = 457)
Variables	n (%)	M(SD)
Gender
Male	163	35.7
Female	294	64.3
Age
Up to 30 years	394	86.2
31 to 45 years	55	12.0
46 to 60 years	7	1.5
61 and above	1	0.2
Marital status Married	93	20.4
Unmarried	364	79.6
Area of living
Urban	339	74.2
Rural	118	25.8
Education
Below matric	5	1.1
Intermediate	28	6.1
Graduation (BS/LLB/MSc, etc.)	321	70.2
Post-graduation (MS/MPhil/ PhD)	103	22.5
Income (in PKR) Up to 50,000	183	40.0
51,000 to 100,000	116	25.4
101,000 to 150,000	67	14.7
151,000 to 200,000	27	5.9
201,000 to 250,000	22	4.8
Above than 250,000	42	9.2

The results regarding central tendency, skewness, and kurtosis of each item indicate that people had agreement with items 1 and 2, whereas they disagreed with items 3, 4, 5 and 6. A distribution of items can be considered normal if values of skewness and kurtosis range between ± 1.5. Our findings show that all of the items were normally distributed because no item had a higher or lesser value than ± 1.5 for skewness and kurtosis (Table 2).

Table 2

Item properties of the PPFVD
	Mean	SD	Skewness	Kurtosis
PPFVD1	2.14	0.887	-0.855	-0.002
PPFVD2	2.19	0.922	-0.871	-0.248
PPFVD3	1.64	1.120	-0.209	-1.321
PPFVD4	1.69	1.131	-0.249	-1.337
PPFVD5	1.79	1.036	-0.271	-1.148
PPFVD6	1.61	1.101	-0.168	-1.291

The results of the inter-item correlations are presented in Table 3. All inter-item correlations were found to be significant and ranged between 0.30 and 0.70, which is considered as a medium to strong association. The value of Cronbach’s alpha was 0.887, indicating good reliability. Corrected item-total correlations ranged between 0.632 and 0.754. Factor loadings ranged from 0.664 to 0.810, indicating a good internal consistency (Table 4).

Table 3

Inter-item correlation matrix
	PPFVD1	PPFVD2	PPFVD3	PPFVD4	PPFVD5	PPFVD6
PPFVD1	1.000
PPFVD2	.680	1.000
PPFVD3	.530	.540	1.000
PPFVD4	.464	.466	.666	1.000
PPFVD5	.458	.443	.575	.674	1.000
PPFVD6	.487	.461	.671	.665	.696	1.000

Table 4

Factor loadings and Cronbach’s alpha results
	Factor loading	Cronbach’s alpha if item deleted	Corrected item: Total correlation
PPFVD1	0.673	0.878	0.632
PPFVD2	0.664	0.879	0.622
PPFVD3	0.805	0.859	0.749
PPFVD4	0.795	0.860	0.741
PPFVD5	0.765	0.864	0.715
PPFVD6	0.810	0.858	0.754

Construct validity

Confirmatory factor analysis was run on the six items of the PPFVD to test one-factor solution of the post pandemic fear of viral diseases. The analysis revealed that model fit indices (CFI = 0.997, RMSEA = 0.035) showed a good fit in the overall sample. The other fit indices (GFI = 0.992, AGFI = 0.976, and RMR = 0.019) also showed a good fit of the sample. In addition, squared multiple correlations for each item were all statistically significant and ranged from 0.34 to 0.70. Overall, these results clearly demonstrate that the one-factor solution model for PPFVD presents a good fit to the data (Fig. 1). The composite reliability (CR = 0.747) was also good and acceptable.

Criterion Validity

Criterion validation was performed through a structured equation modelling analysis. As proposed in this study, PPFVD was taken as the predictor of GAD in in the structural model. The findings revealed an excellent fit to the data (RMR = 0.044; RMSEA = 0.057; GFI = 0.946; AGFI = 0.920; TLI = 0.967; CFI = 0.974). A further inspection to the correlation coefficient provided additional support for the PPFVD’s criterion validity (r = 0.54, R² = 0.29, p < 0.001, 99.9%) (Fig. 2).

The COVID-19 pandemic has a widespread impact on people’s actions and well-being worldwide. The majority still believes that they should be precautious to avoid COVID-19. These preventative measures are now considered the new norm. Because of the severity and magnitude of this pandemic, the threat of a novel viral disease outbreak will persist in the coming years. The findings of this study reflect that this trend is predominantly prevailing among the people. As a result, academics must create a measurement tool to assess the situation in diverse socio-cultural settings. Similar studies have indicated that the anxiety sensitivity has risen due to staying in dwellings during the COVID-19 outbreak [24]. Similarly, positive impact of social media usage on mental health during the pandemic has been observed, which should also be analyzed in post-pandemic circumstances [25].

Another scale, the Fear of Coronavirus Questionnaire (FCV-19S), developed by Mertens and colleagues [26] demonstrated that pandemic fear has slowly decreased since April 2020. Our adapted instrument, the PPFVD, can highlight an increase or decrease in the pandemic fear. There is a dire need to assess the population’s mental health following the pandemic. This scale can assist healthcare practitioners and mental health professionals in determining the prevalence of fear of viral diseases. Most people may believe that COVID-19 is over and that there is no need to worry because this situation will never arise again. Population level of estimation would be required in this regard as it is associated with the preparedness for future pandemics. However, we know that the world may face a similar situation again if a new variant of COVID-19 or another novel virus outbreak occurs. Some other studies have indicated fear attached with flu and cough leading to similar anxiety [27]. However, it is important to distinguish between the utilitarian precautionary behavior from excessive and abnormal fear [28]. Previous research has assessed fear of pandemic among difference populations such as pregnant women [29], students [30], workforce [31], patients [32], and medical staff [33]. The ones who have been economically impacted by the pandemic experienced largest amounts of post-pandemic fear [34].

This study is subject to certain limitations which are linked to the data collection via an online-based survey with a non-random sample of heterogeneous and diverse respondents. Secondly, the validation is based on data collected in the Pakistani context which might raise questions on the external validity. The strength of this study lies in the fact that post-pandemic fear of viral diseases has not yet been investigated internationally. Future researchers are encouraged to test the scale in diverse social contexts. More studies are required to validate the results of this study as well.

In conclusion, the PPFVD is a reliable and valid tool to measure the post-pandemic fear of viral diseases. This measurement scale can be trusted and used to test the PPFVD in post-pandemic situations. The findings of this study have relevance to social and health policy. Moreover, this study contributes to the emerging literature on post-pandemic fear of viral diseases.

AGFI Adjusted goodness of fit index

CFI Composite fit index

COVID-19 Coronavirus disease 2019

CR Composite reliability

FCV-19S Fear of Coronavirus Scale

GAD Generalized anxiety disorder

GFI Goodness of fit index

PPFVD Post-pandemic dear of virus disease

RMR Root mean square residual

RMSEA Root mean square error of approximation

TLI Tucker-Lewis index

Ethics approval and consent to participate

The study has been performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. Participants provided informed consent before the study started. This procedure was reviewed and approved by the Ethical Review Committee, University of the Punjab.

Consent for publication

Not applicable.

Availability of data and materials

Data are available from corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests. FF serves as Academic Editor for BMC Public Health.

Funding

None.

Authors’ contributions

QKM conceptualized the study. QKM was responsible for data collection and data analysis. QKM drafted the first version of the manuscript. AJ, MF, MSA and FF revised it critically for important intellectual content. All authors read and approved the final version of this manuscript.

Acknowledgements

None.

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Competing interest reported. The authors declare that they have no competing interests. FF serves as Academic Editor for BMC Public Health.

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You are reading this latest preprint version

Development and validation of the Post-Pandemic Fear of Viral Disease scale and its relationship with general anxiety disorder: A cross-sectional survey from Pakistan

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Abstract

Figures

Background

Methods

Participants and procedures

Measures

Statistical analyses

Results

Characteristics of participants

Construct validity

Criterion Validity

Discussion

Conclusion

Abbreviations

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References

Additional Declarations

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