The Fear of COVID-19 Scale adaptation and validation

Adaptação e validação da Escala de Medo da COVID-19

André FARO Luanna dos Santos SILVA Daiane Nunes dos SANTOS Amanda Lima Barros FEITOSA About the authors

Abstract

This study aimed to adapt and raise evidences of validity based on the internal structure, on the relationship with other variables, and on the content of the Fear of COVID-19 Scale (FCV-19S) in Brazilian Portuguese. We performed the Confirmatory Factor Analysis of the scale, its invariance analysis by gender, and established norms for interpreting the instrument’s scores. Participants were 1,000 adults of both genders. The findings showed all fit indices as satisfactory, confirming the scale’s one-dimensionality and its invariance. Results also demonstrated convergent validity between the FCV-19S and the stress of the subjects. Moreover, the stratification of the intensity of fear (mild, moderate and severe) was determined based on the standardization of scores. We concluded that FCV-19S presents sufficient evidence to support its use to assess the fear of Covid-19S in Brazil.

Keywords
Confirmatory factor analysis; Coronavírus; Health psychology; Norm

Resumo

Este estudo objetivou adaptar e levantar evidências de validade com base na estrutura interna, na relação com outras variáveis e de conteúdo da Escala de Medo da COVID-19 (EMC-19, Fear of COVID-19 Scale) para português brasileiro. Para tanto, realizou-se a Análise Fatorial Confirmatória da medida e sua análise de invariância por sexo; ademais, estabeleceu--se normas para interpretação dos escores do instrumento. Fizeram parte da pesquisa 1.000 adultos, de ambos os sexos. Os resultados evidenciaram que todos os índices de ajuste foram satisfatórios, confirmando a unidimensionalidade da escala, bem como sua invariância. Constatou-se, ainda, que houve validade convergente entre a EMC-19 e o estresse dos participantes. Além disso, foram propostos estratos de classificação da intensidade do medo (leve, moderado e severo) com base na normatização dos escores. Por fim, concluiu-se que a EMC-19 apresenta evidências suficientes que recomendam a sua utilização para medida do medo da COVID-19 no Brasil.

Palavras-chave
Análise fatorial confirmatória; Coronavírus; Psicologia da saúde; Norma

The coronavirus pandemic, just six months after its emergence, reached the mark of 7.3 million confirmed cases and has already caused more than 400 thousand deaths globally. In June 2020, Brazil stood out as the second country most affected by the pandemic in the world, coming behind only after the United States (Coronavirus Resource Center, 2020Coronavirus Resource Center. (2020). Coronavirus COVID-19 global cases by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University. Johns Hopkins University. http://coronavirus.jhu.edu/map.html
http://coronavirus.jhu.edu/map.html...
). In the first half of that month, Brazil counted more than 38 thousand deaths and about 740 thousand accumulated cases of COVID-19 (Brasil, 2020Brasil. Ministério da Saúde (2020, April 21). Painel coronavirus. Covid Saúde. https://covid.saude.gov.br/
https://covid.saude.gov.br/...
). With an upward curve of confirmed cases, during that month Brazil was the only country in the world that maintained a progressive evolution of the disease, even after the first 100 days of the pandemic had been elapsed (Coronavirus Resource Center, 2020Coronavirus Resource Center. (2020). Coronavirus COVID-19 global cases by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University. Johns Hopkins University. http://coronavirus.jhu.edu/map.html
http://coronavirus.jhu.edu/map.html...
).

The low national rate of adherence to the policy of social distancing and quarantine gave prominence to the problem of combating COVID-19 in Brazil. The records showed that quarantine adherence was lower than 40% by June, despite the official recommendation that 70% would be desirable for controlling the spreading of the virus (Inloco, 2020Inloco. (2020). Mapa brasileiro da COVID-19: índice de isolamento social. Inloco. http://www.inloco.com.br/pt/
http://www.inloco.com.br/pt/...
). Additionally, in the second half of June, even before stabilization or reduction in the number of new cases, the reopening of business and the resumption of other social activities in some cities, especially capitals, that was already taking place, raised concerns about the time extension of the first infection wave in the country. These facts enhanced the expectations of a worsening of the scenario of this public health problem, since Brazil, according to estimates of the World Health Organization, had not yet reached the peak of the disease in that period (World Health Organization, 2020World Health Organization. (2020, December 18). WHO – Press Conference 22/05/2020. https://www.who.int/emergencies/diseases/novel-coronavirus-2019
https://www.who.int/emergencies/diseases...
).

In the face of an epidemic outbreak, the efforts by governments, health teams and the media usually focus on the physical and biological aspects of the disease, neglecting and underestimating psychological implications. However, previous experiences of health crises had already shown that the repercussions on mental health can last longer and be more prevalent than the disease itself (Ornell et al., 2020Ornell, F., Schuch, J. B., Sordi, A. O., & Kessler, F. H. P. (2020). “Pandemic fear” and COVID-19: mental health burden and strategies. Brazilian Journal of Psychiatry, 42(3), 232-235. https://doi.org/10.1590/1516-4446-2020-0008
https://doi.org/10.1590/1516-4446-2020-0...
), indicating the importance of mental health care throughout the epidemic and, especially, after the most acute period of the crisis.

Fear is a central emotion to be considered when trying to understand the psychological effects experienced in a threatening scenario (Ornell et al., 2020Ornell, F., Schuch, J. B., Sordi, A. O., & Kessler, F. H. P. (2020). “Pandemic fear” and COVID-19: mental health burden and strategies. Brazilian Journal of Psychiatry, 42(3), 232-235. https://doi.org/10.1590/1516-4446-2020-0008
https://doi.org/10.1590/1516-4446-2020-0...
), like in the case of COVID-19. Fear is defined as an unpleasant emotional state that is triggered by the perception of threatening stimuli, but that becomes maladaptive when it overlaps actual adversity (Harper et al., 2020Harper, C. A., Satchell, L. P., Fido, D., & Latzman, R. D. (2020). Functional fear predicts public health compliance in the COVID-19 pandemic. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00281-5
https://doi.org/10.1007/s11469-020-00281...
). It is an adaptive emotion that is expressed through levels of emotional avoidance in relation to specific stimuli, aiming to mobilize energies to deal with a potential threat (Perin et al., 2015Perin, C., Beghi, M., Cerri, C. G., Peroni, F., Viganò, B., & Cornaggia, C. M. (2015). Experience of group conversations in rehabilitative medicine: methodological approach and pilot study. Journal of Medicine and the Person, 13, 96-104. https://doi.org/10.1007/s12682-015-0208-7
https://doi.org/10.1007/s12682-015-0208-...
). In the event of widespread public fear caused by pandemic viral infections, it is possible that significant levels of mental suffering will be triggered in the general population, adding to the epidemic situation itself (Harper et al., 2020Harper, C. A., Satchell, L. P., Fido, D., & Latzman, R. D. (2020). Functional fear predicts public health compliance in the COVID-19 pandemic. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00281-5
https://doi.org/10.1007/s11469-020-00281...
). In addition to this initial aspect of acute reaction to the stressful event, the perception of fear is an important indicator of adherence to health behaviors; not complying with those health behaviors in a situation of real threat can result in negligent attitudes and cause individual and/or collective harm (Mertens et al., 2020Mertens, G., Gerritsen, L., Duijndam, S., Salemink, E., & Engelhard, I. M. (2020). Fear of the coronavirus (COVID-19): predictors in an online study conducted in March 2020. Journal of Anxiety Disorders, 74, e102258. https://doi.org/10.1016/j.janxdis.2020.102258
https://doi.org/10.1016/j.janxdis.2020.1...
).

In health crisis contexts, such as in the COVID-19 pandemic, fear can raise stress levels (Ornell et al., 2020Ornell, F., Schuch, J. B., Sordi, A. O., & Kessler, F. H. P. (2020). “Pandemic fear” and COVID-19: mental health burden and strategies. Brazilian Journal of Psychiatry, 42(3), 232-235. https://doi.org/10.1590/1516-4446-2020-0008
https://doi.org/10.1590/1516-4446-2020-0...
) and evidence has shown that the greater the fear of the new coronavirus, the greater the stress rates (Bitan et al., 2020Bitan, D. T., Grossman-Giron, A., Bloch, Y., Mayer, Y., Shiffman, N., & Mendlovic, S. (2020). Fear of COVID-19 scale: psychometric characteristics, reliability and validity in the Israeli population. Psychiatry Research, 289, 1-5. https://doi.org/10.1016/j.psychres.2020.113100
https://doi.org/10.1016/j.psychres.2020....
; Satici, Gocet-Tekin et al., 2020Satici, B., Gocet-Tekin, E., Deniz, M. E., & Satici, S. A. (2020). Adaptation of the Fear of COVID-19 Scale: Its association with psychological distress and life satisfaction in Turkey. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00294-0
https://doi.org/10.1007/s11469-020-00294...
). Stress is a mental and physical repercussion resulting from evaluations of stimuli that are perceived as stressors (social, biological and/or psychological), which demand an adaptive response aimed at restoring the state of well-being or minimization of perceived discomfort (Faro & Pereira, 2013Faro, A., & Pereira, M. E. (2013). Estresse: revisão narrativa da evolução conceitual, perspetivas teóricas e metodológicas. Psicologia, Saúde & Doenças, 14(1), 78-100. https://www.redalyc.org/articulo.oa?id=36226540009
https://www.redalyc.org/articulo.oa?id=3...
). In a situation like the COVID-19 pandemic, a number of stressors have been experienced by the population, especially due to an invisible threat difficult to deal with, which caused abrupt and unexpected changes in the individual routine, family organization and work of practically the entire world population (Ornell et al., 2020Ornell, F., Schuch, J. B., Sordi, A. O., & Kessler, F. H. P. (2020). “Pandemic fear” and COVID-19: mental health burden and strategies. Brazilian Journal of Psychiatry, 42(3), 232-235. https://doi.org/10.1590/1516-4446-2020-0008
https://doi.org/10.1590/1516-4446-2020-0...
).

The Fear of COVID-19 Scale (FCV-19S) was developed with the aim of making available a brief measure to investigate the fear of COVID-19 (Ahorsu et al., 2020Ahorsu, D. K., Lin, C.-Y., Imani, V., Saffari, M., Griffiths, M. D., & Pakpour, A. H. (2020). The Fear of COVID-19 Scale: development and initial validation. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00270-8
https://doi.org/10.1007/s11469-020-00270...
). The scale has already been adapted and validated in more than eight countries, like Greece (Tsipropoulou et al., 2020Tsipropoulou, V., Nikopoulou, V. A., Holeva, V., Nasika, Z., Diakogiannis, I., Sakka, S., Kostikidou, S., Varvara, C., Spyridopoulou, E., & E. Parlapani. (2020). Psychometric properties of the Greek version of FCV-19S. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00319-8
https://doi.org/10.1007/s11469-020-00319...
), Israel (Bitan et al., 2020Bitan, D. T., Grossman-Giron, A., Bloch, Y., Mayer, Y., Shiffman, N., & Mendlovic, S. (2020). Fear of COVID-19 scale: psychometric characteristics, reliability and validity in the Israeli population. Psychiatry Research, 289, 1-5. https://doi.org/10.1016/j.psychres.2020.113100
https://doi.org/10.1016/j.psychres.2020....
), Italy (Soraci et al., 2020Soraci, P., Ferrari, A., Abbiati, F. A., Del Fante, E., Pace, R., Urso, A., & Griffiths, M. D. (2020). Validation and psychometric evaluation of the Italian version of the Fear of COVID-19 Scale. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00277-1
https://doi.org/10.1007/s11469-020-00277...
), Bangladesh (Sakib et al., 2020Sakib, N., Bhuiyan, A. K. M. I., Hossain, S., Al Mamun, F., Hosen, I., Abdullah, A. H., Sarker, A., Mohiuddin, M. S., Rayhan, I., Hossain, M., Sikder, T., Gozal, D., Muhit, M., Islam, S. M. S., Griffiths, M. D., Pakpour, A. H., & Mamun, M. A. (2020). Psychometric validation of the Bangla Fear of COVID-19 Scale: confirmatory factor analysis and Rasch analysis. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00289-x
https://doi.org/10.1007/s11469-020-00289...
), Turkey (Satici, Gocet-Tekin et al., 2020Satici, B., Saricali, M., Satici, S. A., & Griffiths, M. D. (2020). Intolerance of uncertainty and mental wellbeing: serial mediation by rumination and fear of COVID-19. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00305-0
https://doi.org/10.1007/s11469-020-00305...
) and Saudi Arabia (Alyami et al., 2020Alyami, M., Henning, M., Krägeloh, C. U., & Alyami, H. (2020). Psychometric evaluation of the Arabic version of the Fear of COVID-19 Scale. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00316-x
https://doi.org/10.1007/s11469-020-00316...
), and other countries. The instrument has shown good psychometric quality, proving to be a robust measure and with the potential for comparisons of findings among countries. There are also recommendations that future studies with FCV-19S use the Confirmatory Factor Analysis to the detriment of Exploratory Factorial Analysis, since the one-dimensional model of FCV-19S has already been supported in a significant number of studies (Pakpour et al., 2020Pakpour, A. H., Griffiths, M. D., & Lin, C.Y. (2020). Assessing the psychological response to the COVID-19: a response to Bitan et al. “Fear of COVID-19 scale: psychometric characteristics, reliability and validity in the Israeli population”. Psychiatry Research, 290, 113-127. https://doi.org/10.1016/j.psychres.2020.113127
https://doi.org/10.1016/j.psychres.2020....
).

Findings already obtained with the application of the FCV-19S in other countries have already shown that living with chronic illness, being a woman, being married and a health professional were features associated with higher levels of fear (Bakioğlu et al., 2020Bakioğlu, F., Korkmaz, O., & Ercan, H. (2020). Fear of COVID-19 and positivity: mediating role of intolerance of uncertainty, depression, anxiety, and stress. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00331-y
https://doi.org/10.1007/s11469-020-00331...
; Doshi et al., 2020Doshi, D., Karunakar, P., Sukhabogi, J. R., Prasanna, J. S., & Mahajan, S. V. (2020). Assessing coronavirus fear in Indian population using the Fear of COVID-19 Scale. International Journal of Mental Health and Addiction, 1-9. https://doi.org/10.1007/s11469-020-00332-x
https://doi.org/10.1007/s11469-020-00332...
; Tsipropoulou et al., 2020Tsipropoulou, V., Nikopoulou, V. A., Holeva, V., Nasika, Z., Diakogiannis, I., Sakka, S., Kostikidou, S., Varvara, C., Spyridopoulou, E., & E. Parlapani. (2020). Psychometric properties of the Greek version of FCV-19S. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00319-8
https://doi.org/10.1007/s11469-020-00319...
). On the other hand, age, educational level and having a relative diagnosed with the disease did not seem to affect the individuals’ perception of fear (Ahorsu et al., 2020Ahorsu, D. K., Lin, C.-Y., Imani, V., Saffari, M., Griffiths, M. D., & Pakpour, A. H. (2020). The Fear of COVID-19 Scale: development and initial validation. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00270-8
https://doi.org/10.1007/s11469-020-00270...
; Bakioğlu et al., 2020; Sakib et al., 2020Sakib, N., Bhuiyan, A. K. M. I., Hossain, S., Al Mamun, F., Hosen, I., Abdullah, A. H., Sarker, A., Mohiuddin, M. S., Rayhan, I., Hossain, M., Sikder, T., Gozal, D., Muhit, M., Islam, S. M. S., Griffiths, M. D., Pakpour, A. H., & Mamun, M. A. (2020). Psychometric validation of the Bangla Fear of COVID-19 Scale: confirmatory factor analysis and Rasch analysis. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00289-x
https://doi.org/10.1007/s11469-020-00289...
). Furthermore, in relation to the repercussions of this fear, people who reported greater fear of coronavirus showed less satisfaction with life, mental well-being and positivity (Bakioğlu et al., 2020Bakioğlu, F., Korkmaz, O., & Ercan, H. (2020). Fear of COVID-19 and positivity: mediating role of intolerance of uncertainty, depression, anxiety, and stress. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00331-y
https://doi.org/10.1007/s11469-020-00331...
; Satici, Saricali et al., 2020Satici, B., Gocet-Tekin, E., Deniz, M. E., & Satici, S. A. (2020). Adaptation of the Fear of COVID-19 Scale: Its association with psychological distress and life satisfaction in Turkey. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00294-0
https://doi.org/10.1007/s11469-020-00294...
; Satici, Gocet-Tekin et al., 2020Satici, B., Gocet-Tekin, E., Deniz, M. E., & Satici, S. A. (2020). Adaptation of the Fear of COVID-19 Scale: Its association with psychological distress and life satisfaction in Turkey. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00294-0
https://doi.org/10.1007/s11469-020-00294...
).

It is acknowledged that having available a COVID-19 fear measure validated for use in a Brazilian context is relevant, since the lack of appropriate psychometric instruments makes it impossible to achieve a comprehensive view of the care needed for the current situation. In addition, it must be considered that the effects of the pandemic, whether direct or indirect, are affecting the population’s mental health at this time and possibly will continue affecting for some time (Faro et al., 2020Faro, A., Bahiano, M. D. A., Nakano, T. D. C., Reis, C., Silva, B. F. P. D., & Vitti, L. S. (2020). COVID-19 e saúde mental: a emergência do cuidado. Estudos de Psicologia (Campinas), 37, e200074 1-14. https://doi.org/10.1590/1982-0275202037e200074
https://doi.org/10.1590/1982-0275202037e...
; Holmes et al., 2020Holmes, E. A., O’Connor, R. C., Perry, V. H., Tracey, I., Wessely, S., Arseneault, L., Ballard, C., Christensen, H., Silver, R. C. S., Everall, I., Ford, T., John, A., Kabir, T., King, K., Madan, I., Michie, S., Przybylski, A. K., Shafran, R., Sweeney, A., … Bullmore, E. (2020). Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. Lancet Psychiatry, 7(6), 547-560. https://doi.org/10.1016/S2215-0366(20)30168-1
https://doi.org/10.1016/S2215-0366(20)30...
). Therefore, a measurement instrument for one-off, seasonal and longitudinal monitoring of how people perceive and deal with the fear of COVID-19 is relevant. Given the above, this study aimed to: (1) adapt the FCV-19S to Brazilian Portuguese, (2) gather evidence of its validity based on the content, the internal structure and the relationship with the external variable, (3) analyze its invariance by gender and (4) establish norms for the interpretation of the scale scores.

Method

Participants

The sample consisted of 1,000 adults, with an average age of 30.9 years (SD = 12.06; (SD = 12.06; Minimum [Min.] = 18 and Maximum [Max.] = 70), mostly made up of women (79.9%), with a higher education level (78.5%). The Northeast region was predominant (58.1%), followed by the Southeast (26.5%), South (8, 5%), Center-West (4.2%) and North (2.7%). The research design was non-probabilistic and for convenience, and the data were collected through an online questionnaire between June 3 and June 4, 2020.

Instruments

FCV-19S (Ahorsu et al., 2020Ahorsu, D. K., Lin, C.-Y., Imani, V., Saffari, M., Griffiths, M. D., & Pakpour, A. H. (2020). The Fear of COVID-19 Scale: development and initial validation. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00270-8
https://doi.org/10.1007/s11469-020-00270...
) consists of one-dimensional measure, containing seven items (for example, “I am afraid of dying because of COVID-19.” – Item 4), with Likert-type scale answers ranging from 1 (I strongly disagree) to 5 (I totally agree). The total score is obtained from the sum of the items, ranging from 7 to 35 points (range: 28 points), in which the higher the score, the greater the feeling of fear of the disease. In the original scale development study, Cronbach’s alpha was 0.82, considered good (George & Mallery, 2003George, D., & Mallery, P. (2003). SPSS for Windows step by step: a simple guide and reference. 11.0 update (4th ed.). Allyn & Bacon.). In other measurement validation studies, the lowest value (α = 0.80) was found in the study of Reznik et al. (2020)Reznik, A., Gritsenko, V., Konstantinov, V., Khamenka, N., & Isralowitz, R. (2020). COVID-19 fear in Eastern Europe: validation of the Fear of COVID-19 Scale. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00283-3
https://doi.org/10.1007/s11469-020-00283...
and the highest value (α = 0.88) in Alyami et al. (2020)Alyami, M., Henning, M., Krägeloh, C. U., & Alyami, H. (2020). Psychometric evaluation of the Arabic version of the Fear of COVID-19 Scale. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00316-x
https://doi.org/10.1007/s11469-020-00316...
. The Brazilian Portuguese version of the FCV-19S is available in the Table 1.

Table 1
Brazilian Portuguese version of the Fear of COVID-19 Scale (FCV-19S)

To analyze the evidence of validity based on the relationship with other variables, the Perceived Stress Scale (PSS-10) was used, arranged on a scale of 1 (never) to 5 (always) points. The participant was asked how often (in the last month) he/she “Got sad because of something that happened unexpectedly” (Item 1) or “Had to control life irritations” (Item 7). The higher the score, the higher the stress level perceived. In the scale validation study, Cronbach’s alpha was 0.88 (Faro, 2013Faro, A. (2013). Estresse e estressores na pós-graduação: estudo com mestrandos e doutorandos no Brasil. Psicologia: Teoria e Pesquisa, 29, 51-60. https://doi.org/10.1590/S0102-37722013000100007
https://doi.org/10.1590/S0102-3772201300...
). In this study, it was 0.90 and was considered excellent (George & Mallery, 2003George, D., & Mallery, P. (2003). SPSS for Windows step by step: a simple guide and reference. 11.0 update (4th ed.). Allyn & Bacon.).

Finally, a sociodemographic questionnaire containing information was used to characterize the sample, including age (in years), gender (female or male), education (up to elementary school, high school and higher education) and participants’ geographic region (North, Northeast, Midwest, Southeast and South).

Procedures

The process of translating and adapting the FCV-19S to Brazilian Portuguese followed the recommended technical guidelines (Borsa et al., 2012Borsa, J. C., Damásio, B. F., & Bandeira, D. R. (2012). Adaptação e validação de instrumentos psicológicos entre culturas: Algumas considerações. Paideia, 22(53), 423-432. https://doi:10.1590/1982-43272253201314
https://doi.org/10.1590/1982-43272253201...
). The scale was translated by two translators and the two versions being merged into a single translation. Theoretical and structural compatibility was attested by three expert judges, who considered the items and response scale adequate, with no suggestion to introduce significant changes in terms of content or wording. Then, the scale was evaluated by a group of university students, in a pilot collection procedure (n = 40); the students also considered all items and response modalities clear, with no suggestions for adjusting the instrument.

This study was approved by the National Research Ethics Committee (Comissão Nacional de Ética em Pesquisa, registration nº 30485420.6.0000.0008). Participants were approached through invitations on digital media, using the snowball method, and only participants over the age of 18 were included. The Free and Informed Consent Form was provided as the first page of the form and only after consent confirmation, did the individual have access to the research questionnaire.

Data Analysis

The Confirmatory Factor Analysis (CFA) was conducted using JASP (version 0.12.2), adopting Robust Diagonally Weighted Least Squares (DWLS) as an estimation method. The model adequacy adjustment indexes used were the Comparative Fit Index (CFI: desirable > 0.950); the (GFI: desirable > 0.950); the Tucker Lewis Index (TLI; desirable > 0.950) (Hair et al., 2009Hair, J. F., Black, W. C., Babin, B. J., Anderson, R. E., & Tatham, R. L. (2009). Análise multivariada de dados. Bookman Companhia Editora.); the Root Mean Square Error of Approximation (RMSEA: desirable < 0.080) and the Standardized Root Mean Square Residual (SRMR: desirable < 0.080) (Hu & Bentler, 1998Hu, L., & Bentler, P. M. (1998). Fit indices in covariance structure modeling: sensitivity to underparameterized model misspecification. Psychological Methods, 3, 424-453. https://doi.org/10.1037/1082-989X.3.4.424
https://doi.org/10.1037/1082-989X.3.4.42...
). The model invariance was evaluated at the configural, metric, scalar and strict levels, using Delta CFI (ΔCFI: expected ≤ 0.01) and Delta RMSEA (ΔRMSEA: expected ≤ 0.015) as a parameter for rejection of invariance (Chen, 2007Chen, F. F. (2007). Sensitivity of goodness of fit indexes to lack of measurement invariance. Structural Equation Modeling, 14, 464-504. https://doi/10.1080/10705510701301834
https://doi.org/10.1080/1070551070130183...
; Hair et al., 2014Hair, J., Black, W., Babin, B., Anderson, R., & Tatham, R. (2014). Multivariate data analysis. Prentice Hall.). The relationship between the fear score and its categories in relation to the stress score (Pearson’s correlations and ANOVA), Cronbach’s alpha (α: expected > 0.60) and the standardization of the FCV-19S items were calculated in the SPSS (v. 25). Standardization was carried out based on the general classification in percentiles (5% intervals) and calculation of the T score [(Z score of the score * 10) + 50].

Results

The CFA confirmed the one-dimensionality of the FCV-19S, exhibiting all fit indexes with satisfactory values [CFI (0.986), GFI (0.992), TLI (0.980), RMSEA (0.066) and SRMR (0.060)]. The factorial loads of the items varied between 0.570 (item 2) and 0.814 (item 7) (M = 0.686; SD = 0.08), thus maintaining the same structure as the original FCV-19S. Cronbach’s alpha was 0.864 (Table 2). As for the analysis of invariance, the model obtained was invariant by gender (female or male) at all levels of measurement (configural, metric, scalar and strict). The average of the total score of the sample in the FCV-19S was 22.2 (SD = 5.78), with a minimum score of 7 points and a maximum score of 35 points. The stratification of the scores occurred in 3 strata (approximately 33.3% each), namely: from 7 to 19 points the stratum was classified as “mild fear”; 20 to 26 points as “moderate fear” and from 27 points as “severe fear”. Most participants had “moderate fear” of COVID-19 (38.8%), followed by “mild fear” (31.8%) and “severe fear” (29.4%). In the PSS-10, the mean score was 31.8 points (SD = 3.25).

Table 2
Psychometric properties of the Fear of COVID-19 Scale (FCV-19S)

The correlation between the FCV-19S and PSS-10 scores was statistically significant, of moderate and positive strength (r = 0.451; p < 0.001). ANOVA attested to the existence of a relationship between stress and fear levels of COVID-19 [F (2, 997) = 94.72; p < 0.001]. The average scores per stratum were 32.0 (SD = 7.70) in the “mild fear” group, 36.3 (SD = 6.47) in the “moderate fear” and 39.6 (SD = 5,76) in “severe fear” (post-hoc Games-Howell at p < 0.001 for all comparisons). The standardization of the FCV-19S indexes was carried out according to the distribution of the total sample. The 5th and 95th percentiles had, in the total population, T scores of 34 (13 points) and 67 (32 points), respectively. The average T score (50th percentile) was 22 points, which was basically the same (22.2) as the average of the sample’s gross score (Table 3).

Table 3
Standardization of FCV-19S according to total distribution

Discussion

The present study aimed to adapt the FCV-19S and the results indicated satisfactory evidence of the scale’s validity confirming the pertinence of using the version adapted for Brazilian Portuguese. Parameters for the interpretation of the FCV-19S scores were also established by standardizing the distribution of the phenomenon in the total population, providing cut-off points for the scale in terms of population’s fear severity (mild, moderate and severe).

The data indicated one-dimensionality of the FCV-19S and this finding corroborates the results of the original study of the measure (Ahorsu et al., 2020Ahorsu, D. K., Lin, C.-Y., Imani, V., Saffari, M., Griffiths, M. D., & Pakpour, A. H. (2020). The Fear of COVID-19 Scale: development and initial validation. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00270-8
https://doi.org/10.1007/s11469-020-00270...
) and other investigations that sought to provide evidence of the scale’s validity (Sakib et al., 2020Sakib, N., Bhuiyan, A. K. M. I., Hossain, S., Al Mamun, F., Hosen, I., Abdullah, A. H., Sarker, A., Mohiuddin, M. S., Rayhan, I., Hossain, M., Sikder, T., Gozal, D., Muhit, M., Islam, S. M. S., Griffiths, M. D., Pakpour, A. H., & Mamun, M. A. (2020). Psychometric validation of the Bangla Fear of COVID-19 Scale: confirmatory factor analysis and Rasch analysis. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00289-x
https://doi.org/10.1007/s11469-020-00289...
; Satici, Gocet-Tekin et al., 2020; Soraci et al., 2020Soraci, P., Ferrari, A., Abbiati, F. A., Del Fante, E., Pace, R., Urso, A., & Griffiths, M. D. (2020). Validation and psychometric evaluation of the Italian version of the Fear of COVID-19 Scale. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00277-1
https://doi.org/10.1007/s11469-020-00277...
; Tsipropoulou et al., 2020Tsipropoulou, V., Nikopoulou, V. A., Holeva, V., Nasika, Z., Diakogiannis, I., Sakka, S., Kostikidou, S., Varvara, C., Spyridopoulou, E., & E. Parlapani. (2020). Psychometric properties of the Greek version of FCV-19S. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00319-8
https://doi.org/10.1007/s11469-020-00319...
). Only two studies were identified in the literature in which the internal structure of the measure indicated the presence of two factors (Bitan et al., 2020Bitan, D. T., Grossman-Giron, A., Bloch, Y., Mayer, Y., Shiffman, N., & Mendlovic, S. (2020). Fear of COVID-19 scale: psychometric characteristics, reliability and validity in the Israeli population. Psychiatry Research, 289, 1-5. https://doi.org/10.1016/j.psychres.2020.113100
https://doi.org/10.1016/j.psychres.2020....
; Reznik et al., 2020Reznik, A., Gritsenko, V., Konstantinov, V., Khamenka, N., & Isralowitz, R. (2020). COVID-19 fear in Eastern Europe: validation of the Fear of COVID-19 Scale. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00283-3
https://doi.org/10.1007/s11469-020-00283...
). The study by Bitan et al. (2020)Bitan, D. T., Grossman-Giron, A., Bloch, Y., Mayer, Y., Shiffman, N., & Mendlovic, S. (2020). Fear of COVID-19 scale: psychometric characteristics, reliability and validity in the Israeli population. Psychiatry Research, 289, 1-5. https://doi.org/10.1016/j.psychres.2020.113100
https://doi.org/10.1016/j.psychres.2020....
was severely criticized by the authors of the original version of the scale since the factorial structure had been forced without theoretical justifications. In the study by Reznik et al. (2020)Reznik, A., Gritsenko, V., Konstantinov, V., Khamenka, N., & Isralowitz, R. (2020). COVID-19 fear in Eastern Europe: validation of the Fear of COVID-19 Scale. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00283-3
https://doi.org/10.1007/s11469-020-00283...
, the internal structure was obtained from the Principal Component Analysis, a technique considered outdated for factor retention (Damásio, 2012Damásio, B. F. (2012). Uso da análise fatorial exploratória em psicologia. Interamerican Journal of Psychological Assessment, 11(2), 213-228. http://pepsic.bvsalud.org/scielo.php?script=sci_abstract&pid=S1677-04712012000200007
http://pepsic.bvsalud.org/scielo.php?scr...
). Therefore, the one-dimensional structure of FCV-19S, obtained in this study, proved to be stable in different cultures.

The FCV-19S showed variability compatible with the PSS-10, a scale considered to be the gold standard and mostly used to assess stress (Taylor, 2015Taylor, J. M. (2015). Psychometric analysis of the ten-item Perceived Stress Scale. Psychological Assessment, 27(1), 90-101. https://doi.org/10.1037/a0038100
https://doi.org/10.1037/a0038100...
). The analysis of evidence based on the relationship with other variables indicated a statistically significant association between the fear and stress scores. Fear and stress are phenomena that tend to be concomitant, that is, the fear emotion tends to be associated with stress responses and these stress responses directly influence the coping capacity of individuals (Faro & Pereira, 2013Faro, A., & Pereira, M. E. (2013). Estresse: revisão narrativa da evolução conceitual, perspetivas teóricas e metodológicas. Psicologia, Saúde & Doenças, 14(1), 78-100. https://www.redalyc.org/articulo.oa?id=36226540009
https://www.redalyc.org/articulo.oa?id=3...
; Raio & Phelps, 2015Raio, C. M., & Phelps, E. A. (2015). The influence of acute stress on the regulation of conditioned fear. Neurobiology of Stress, 1, 134-146. https://doi.org/10.1016/j.ynstr.2014.11.004
https://doi.org/10.1016/j.ynstr.2014.11....
). In the context of a pandemic, the perception of fear can increase the stress levels of healthy people and enhance symptoms in those with some psychiatric disorder, being an important predictor of health behaviors (Shigemura et al., 2020Shigemura, J., Ursano, R. J., Morganstein, J. C., Kurosawa, M., & Benedek, D. M. (2020). Public responses to the novel 2019 coronavirus (2019-nCoV) in Japan: mental health consequences and target populations. Psychiatry and Clinical Neurosciences, 74(4), 281-282. https://doi.org/10.1111/pcn.12988
https://doi.org/10.1111/pcn.12988...
), a fact that was highlighted in this investigation.

Another objective of the present study was to assess the invariance of the FCV-19S model by gender. It was concluded that the model was invariant in the configural (equivalence in the model configuration), metric (equivalence of factorial loads), scalar (equivalence in the intercept levels of the items) and strict (equivalence of the measurement errors) (Damásio, 2013Damásio, B. F. (2013). Contribuições da Análise Fatorial Confirmatória Multigrupo (AFCMG) na avaliação de invariância de instrumentos psicométricos. Psico-USF, 18(2), 211-220. https://doi/10.1590/S1413-82712013000200005
https://doi.org/10.1590/S1413-8271201300...
; Milfont & Fisher, 2010Milfont, T. L., & Fisher, R. (2010). Testing measurement invariance across groups: applications in cross-cultural research. International Journal of Psychological Research, 3, 111-121. https://doi.org/10.21500/20112084.857
https://doi.org/10.21500/20112084.857...
). This means that the factorial structure of the measure and the factorial loads of the items are the same for the groups of men and women. In addition, the items show similar measurement error between the two groups, allowing the comparison of scores to be psychometrically valid (Damásio, 2013Damásio, B. F. (2013). Contribuições da Análise Fatorial Confirmatória Multigrupo (AFCMG) na avaliação de invariância de instrumentos psicométricos. Psico-USF, 18(2), 211-220. https://doi/10.1590/S1413-82712013000200005
https://doi.org/10.1590/S1413-8271201300...
). Similar findings were also observed in studies that assessed the FCV-19S psychometric properties in Iran (Ahorsu et al., 2020Ahorsu, D. K., Lin, C.-Y., Imani, V., Saffari, M., Griffiths, M. D., & Pakpour, A. H. (2020). The Fear of COVID-19 Scale: development and initial validation. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00270-8
https://doi.org/10.1007/s11469-020-00270...
) and Bangladesh (Sakib et al., 2020Sakib, N., Bhuiyan, A. K. M. I., Hossain, S., Al Mamun, F., Hosen, I., Abdullah, A. H., Sarker, A., Mohiuddin, M. S., Rayhan, I., Hossain, M., Sikder, T., Gozal, D., Muhit, M., Islam, S. M. S., Griffiths, M. D., Pakpour, A. H., & Mamun, M. A. (2020). Psychometric validation of the Bangla Fear of COVID-19 Scale: confirmatory factor analysis and Rasch analysis. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00289-x
https://doi.org/10.1007/s11469-020-00289...
). Therefore, for future scale applications, the findings of the present investigation support that the FCV-19S scores can be validly and reliably compared between genders.

It was observed that, in general, the participants experienced a moderate level of fear, with an average of 22 points. The current epidemic context, which is marked by routine disruption, the imposition of social distancing, economic insecurity and the characteristics of COVID-19 (highly contagious and high level of mortality), help to explain the wide feeling of fear experienced at this time (Harper et al., 2020Harper, C. A., Satchell, L. P., Fido, D., & Latzman, R. D. (2020). Functional fear predicts public health compliance in the COVID-19 pandemic. International Journal of Mental Health and Addiction. https://doi.org/10.1007/s11469-020-00281-5
https://doi.org/10.1007/s11469-020-00281...
). Therefore, establishing cutoff points for the scale in terms of fear severity (mild, moderate and severe) seems to be beneficial, as it allows classification into groups of higher and lower risk, as well as fluctuations over time.

From the findings of this study, it is understood that individuals in the severe fear category should be given priority in mental health care, even though those at a moderate level of fear should also be included in the assistance focus. Common mental disorders, such as anxiety and depression, have been found to be associated with fear at significant levels (moderate and high) in serious public health crises such as the current one, which demonstrates the importance of paying attention to this emotion (Shigemura et al., 2020Shigemura, J., Ursano, R. J., Morganstein, J. C., Kurosawa, M., & Benedek, D. M. (2020). Public responses to the novel 2019 coronavirus (2019-nCoV) in Japan: mental health consequences and target populations. Psychiatry and Clinical Neurosciences, 74(4), 281-282. https://doi.org/10.1111/pcn.12988
https://doi.org/10.1111/pcn.12988...
). In addition, people with severe fear may have an erroneous perception of the threat, which can lead to undesirable behaviors and even increased exposure to the threatening stimulus (Van Bavel et al., 2020Van Bavel, J. J., Baicker, K., Boggio, P. S., Capraro, V., Cichocka, A., Cikara, M., Crockett, M. J., Crum, A. J., Douglas, K. M., Druckman, J. N., Drury, J., Dube, O., Ellemers, N., Finkel, E. J., Fowler, J. H., Gelfand, M., Han, S., Haslam, S. A., Jetten, J., ... Willer, R. (2020). Using social and behavioral science to support COVID-19 pandemic response. PsyArXiv. https://doi.org/10.31234/osf.io/y38m9
https://doi.org/10.31234/osf.io/y38m9...
). Regarding the group of individuals who were mildly afraid, it is important to highlight that this does not reflect a greater capacity for protection in connection with the crisis, since excessively reduced fear, when in an actual threatening situation, can cause a false sense of security and greater exposure to risk factors (Van Bavel et al., 2020Van Bavel, J. J., Baicker, K., Boggio, P. S., Capraro, V., Cichocka, A., Cikara, M., Crockett, M. J., Crum, A. J., Douglas, K. M., Druckman, J. N., Drury, J., Dube, O., Ellemers, N., Finkel, E. J., Fowler, J. H., Gelfand, M., Han, S., Haslam, S. A., Jetten, J., ... Willer, R. (2020). Using social and behavioral science to support COVID-19 pandemic response. PsyArXiv. https://doi.org/10.31234/osf.io/y38m9
https://doi.org/10.31234/osf.io/y38m9...
).

Conclusion

In summary, the adaptation of FCV-19S to Brazilian Portuguese allows future research in Brazil using an instrument with adequate psychometric properties to assess the fear of COVID-19 in the population. The establishment of the cutoff points and the determination of the T score performed in this work favor the parameterization of this scale scores distribution in other contexts. It also allows comparison of different research scenarios. In addition, this findings standardization allows monitoring the scores at different points in time in the COVID-19 crisis in the country. For Brazil, this appears to be important, as some sites are in the pre-crisis phase (few cases of COVID-19 but growing) and others in the intra-crisis phase (significant increase of cases, hospitalizations and deaths), but there are municipalities that still do not record deaths related to coronavirus or have rare cases recorded, even in mid-June 2020.

As limitations of this work, it is worth noting that the data were collected at the time when Brazil was in the period of intra-crisis, that is, the reading of findings should be made based on this period of the pandemic. Another limitation is that the sample, although large, is not randomized, which does not allow to infer that it represents the entire Brazilian population, especially in the South, North and Center-West regions, which participation was quite small. Finally, it is worth noting that this research presented a short instrument, easy to use and to apply by health professionals and managers. Consequently, it is hoped that mapping the fear of COVID-19, in different locations over the country, will allow a better understanding in the future of how people are dealing with the pandemic. Thus, the FCV-19S is intended to contribute to the development of interventions in mental health and to the implementation of more appropriate health behaviors to cope with the pandemic.

How to cite this article

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Publication Dates

  • Publication in this collection
    03 June 2022
  • Date of issue
    2022

History

  • Received
    18 June 2020
  • Reviewed
    10 Mar 2021
  • Accepted
    27 May 2021
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