|Year : 2020 | Volume
| Issue : 3 | Page : 142-151
Development of the COVID-19 Phobia Scale: Validity and Reliability Study
Nesrin Dilbaz1, Onur Cemal Noyan1, Gul Alpar2, Ozlem Kizilkurt Kazan3
1 Department of Psychiatry, Faculty of Medicine, Uskudar University, Istanbul, Turkey
2 Department of Juvenile Division of the Istanbul Police, Uskudar University, Istanbul, Turkey
3 Department of Psychology, Uskudar University, Istanbul, Turkey
|Date of Submission||20-Oct-2020|
|Date of Decision||12-Nov-2020|
|Date of Acceptance||13-Nov-2020|
|Date of Web Publication||25-Dec-2020|
Onur Cemal Noyan
Department of Psychiatry, Faculty of Medicine, Uskudar University, Istanbul
Source of Support: None, Conflict of Interest: None
Objective: It is suggested that the psychological and emotional reactions that occurred during the COVID-19 pandemic may lead to serious psychiatric disorders in the long run. This study aims to establish the validity and reliability of the COVID-19 Phobia Scale developed for measuring emotions and behaviors related to the COVID-19 pandemic. Methods: The sociodemographic form, COVID-19 Phobia Scale developed by the researchers, Hospital Anxiety and Depression Scale, and Health Anxiety Scale were applied in the study conducted through a web-based survey method. Results: An item-total analysis was performed as the first step of the study that was conducted with 1243 participants. The exploratory and confirmatory factor analyses revealed the final version of the COVID-19 Phobia Scale to comprise four subscales made up of 22 items, where the subscales were termed as worry, mood, reassurance seeking/precaution, and avoidance. The internal consistency of the COVID-19 Phobia Scale measured by the Cronbach's alpha coefficient was 0.84. A statistically significant positive correlation was found between the COVID-19 Phobia Scale and Hospital Anxiety and Depression Scale, Health Anxiety Scale. Conclusion: The COVID-19 Phobia Scale is a valid and reliable scale that can be used to measure emotions and related behavioral changes.
Keywords: COVID-19, phobia, scale, worry
|How to cite this article:|
Dilbaz N, Noyan OC, Alpar G, Kazan OK. Development of the COVID-19 Phobia Scale: Validity and Reliability Study. J Neurobehav Sci 2020;7:142-51
| Introduction|| |
From the beginning of 2020, COVID-19 cases caused by 2019-nCoV – a new type of coronavirus that was never detected in humans before – were observed with symptoms such as respiratory distress, fever, joint pain, and a high risk of mortality. Following the announcement of rapidly increasing incidents of cases and fatalities from numerous countries, the World Health Organization (WHO) announced a global pandemic by specifying the personal protective measures that are to be taken. Globally, there have been 40 million confirmed cases of COVID-19, including 1 million deaths, reported to the WHO, while the number of detected cases in Turkey was 340.000 with 9300 deaths.
The behavioral or emotional reactions demonstrated by society during the pandemic period, which affects many people in the world and has different psychological effects on every individual, determine the progress of the pandemic., These emotional reactions can vary from fear and paranoia to indifference., Moderate levels of fear and anxiety are known to motivate individuals to cope with threats to health, whereas severe levels of anxiety might affect them more negatively. As a result of a chain of psychological reactions, some individuals experience severe anxiety accompanied by symptoms such as distress, avoidance, and decreased functionality that may require treatment. Just like the concept of SARS phobia was coined during the SARS epidemic, the term coronaphobia, which defined unreasonable fear of the coronavirus transmission, started to be used in many countries during this period., It is speculated that as the virus was a novel discovery, the obscurity of negative scenarios, it might lead to and the information pollution in media led to the emergence of the coronaphobia concept, although the number of cases and fatalities resulting from seasonal influenza infections was found to be much higher than that of COVID-19. Individuals with severe anxiety and fear of being infected with the virus might demonstrate behaviors that are not recommended by experts, such as withdrawal and taking extreme precautions to protect oneself from the risks. Although the impact of COVID-19 on mental health is yet not fully known, research on previous epidemics and pandemics suggests that individual trait differences such as intolerance toward uncertainty, perceived vulnerability to disease, and tendency toward anxiety might be significant contributing factors to the emergence of serious psychiatric disorders, such as depression, posttraumatic stress disorder, and alcohol/substance abuse.,, Individuals with high levels of health anxiety start thinking that they are infected with the disease by misinterpreting their physical sensations, which are physiological. These misinterpretations consequently might lead to certain negative behaviors that can even lead to self-harm by disrupting healthy decision-making abilities due to increased levels of anxiety., Moreover, some individuals with high levels of health anxiety might demonstrate unhealthy behavior due to their anxiety of getting infected, such as avoiding consulting health institutions and refraining from availing health services that they need. Furthermore, some individuals tend to show maladaptive behaviors, such as overstocking food, excessive handwashing, locking themselves in their house, and avoiding any kind of physical contact, as a result of the severe anxiety, which can be termed as fear, due to the informational convergence resulting from their constant struggle to research and obtain the right information. Conversely, other individuals with low levels of health anxiety tend to disobey the recommended procedures with the mindset that nothing will happen to them, and thus pose a considerable risk in terms of infectiousness. Psychoneuroimmunology studies demonstrate that adverse emotions and stressful incidents in life might increase the susceptibility to infection by adversely affecting the immune system, suggesting that anxiety is a psychological symptom that should carefully be considered during the pandemic period. Only a limited number of structured psychometric measurement tools that facilitate evaluating emotions and behaviors observed during infections or epidemics exist. It is noteworthy that in former times during pandemics, research was conducted with scales constructed by researchers that were not specific to the pandemic; however, a 7-question COVID-19 fear scale was constructed by Iranian researchers in March 2020.,,,, Studies generally focus on diagnosis and treatment during pandemics, while research on the psychological effects of pandemics is usually conducted toward the end of the pandemic or once it is over. Simple and rapid psychometric measurement tools that facilitate the evaluation of general status in terms of facilitating the determination of risky individuals for the psychological effects of pandemics are thus needed. Research conducted suggests the significance of investigating the symptoms of anxiety and depression with scales at the initial stage. Assessing the rapid changes in human emotions and behavior throughout the pandemic will make it easier for us to prepare for new epidemics or disasters. The aim of this study, in this sense, was to demonstrate the validity and reliability of the COVID-19 Phobia Scale constructed for prioritization of symptoms such as worry, avoidance, precaution, and mood changes caused by the coronavirus pandemic in Turkey.
| Methods|| |
The ethics committee approval has been obtained from Üsküdar University Non-Interventional Clinical Research Ethics Committee (61351342/2020-227). The current study was carried out through an internet survey. The link for the survey form prepared through SurveyMonkey was sent to the participants through various social media and e-mail groups. After confirming their participation in the current study from the first page of the survey that was displayed right after clicking the electronic link, the participants proceeded to the survey questions and completed the study.
- COVID-19 Phobia Scale
Development of the COVID-19 Phobia Scale comprised three stages. A 60-item question pool was compiled by the researchers during the first stage, mainly using past research that related to psychological disorders that arise during pandemics and the researchers' experience on the subject matter. During the second stage, six different experts working in the field of mental health (psychiatrists, psychologists, and academics) evaluated the questions in terms of parameters that they wanted to measure, namely comprehensibility and quality. Seventeen items were deleted from the draft form concerning scores assigned to items by the experts, and research continued with the remaining 43-item scale. At the third stage, selected items were restructured for a 5-point Likert scale and applied to a group of 15 people to be tested for question clarity. Finally, the COVID-19 Phobia Scale was applied to the specified sample group for further validity and reliability studies.
- Sociodemographic Information Form: This form was prepared by researchers based on information obtained from the literature. The form included questions on sociodemographic information of participants, such as gender, age, educational status, current job description, health problems, and attitudes related to coronavirus
- Hospital Anxiety and Depression Scale: The Turkish adaptation of the scale developed in 1983 by Aydemir et al. in 1997 was used. The 4-point Likert type scale with 0–3 scoring comprised a total of 14 items, where seven questions were related to anxiety and the remaining seven with depression. The higher scores pointed out the greater severity of anxiety and depression
- Health Anxiety Scale: The Turkish adaptation of the 18-item self-report type Health Anxiety Scale developed by Salkovskis et al. was conducted by Aydemir et al. The internal consistency in terms of Cronbach's alpha was found to be 0.918 in reliability analysis. The score range of items was 0–3, and higher scores indicated higher levels of health anxiety.
Data collected in the study were statistically analyzed using Statistical Package for Social Sciences (SPSS) version 21 (IBM Corp., Armonk, N.Y., USA). Correlation coefficients between total scores of the scale and items of the scale were calculated before proceeding to the validity analysis of the COVID-19 Phobia Scale, and items with r < 0.20 were deleted from the scale. Following the item analysis, the lowest factor load was taken as 0.300 during the exploratory factor analysis, and the remaining items were subjected to obliquely rotated principal components analysis. Items obtained as a result of five-step obliquely rotated principal components analysis were then evaluated in terms of their logical features and certain items were distributed to other factors. Cronbach's alpha reliability coefficients were calculated for the scale and subscales obtained as a result of the analysis and items decreasing the reliability were deleted from the scale at this point. Model-data fit was then analyzed for the obtained model by conducting the first- and second-order confirmatory factor analysis. The lower and upper group averages of 27% were compared with independent samples t-test for calculating the scale's discriminant validity.
| Results|| |
The study population comprised N = 1243 participants with ages ranging from 20 to 78 years (age average. =44.74; standard deviation [SD] =13.061), where 738 were female (age ave. =42.94; SD = 12.824), 497 were male (age ave. =47.51; SD = 12.977) and eight refraining from providing their gender information (age ave. =37.49; SD = 8.655). Participants joined the study voluntarily and were randomly selected. The sociodemographic characteristics of participants are shown in [Table 1].
|Table 1: Frequency distributions and percentages of participants' sociodemographic properties|
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Before proceeding to reliability and validity studies, item analysis for the 43-item COVID-19 Phobia Scale was conducted in terms of correlation of each item in the scale with the total score of the scale. As a result of the first round of Spearman correlation analysis conducted during item analysis, items 2, 22, 28, and 31 were found to correlate 0.20 with the item-total score and thus were deleted from the scale. Correlations of the remaining 39 items with the total item score were found to range between 0.234 (item 3) and 0.711 (item 20), according to the correlation analysis results obtained with the new total score after deletion of these items from the scale. Factor analysis was then performed as the correlations of the remaining 39 items with the total score were found to be r > 0.20. Item-total scores and correlation coefficients for 39 items are shown in [Table 2].
|Table 2: Findings of Spearman correlation analysis for item-total scores of 39 items and individual items|
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The exploratory factor analysis procedure was conducted with obliquely rotated principal components analysis (KMO = 0.948; Bartlett test (741) =17745, 116; P < 0.001) for all 39 items that remained after item analysis of the COVID-19 Phobia Scale. As a result of the analysis, an 8-factor structure with 39 items having an eigenvalue above 1 was obtained, explaining 53.81% of the variance. Considering the items with factor loads above 0.30, I37, I10, I38, and I42 were observed to have factor loads on multiple factors; however, the difference between these loads was <0.10. These items, therefore, were eliminated from the scale, and a second factor analysis was then applied. All 35 remaining items were subjected to obliquely rotated basic components analysis (KMO = 0.939; Bartlett test (595) =14726.081; P < 0.001). As a result of the analysis, a 7-factor structure with 35 items having an eigenvalue above 1 was obtained, explaining 51.75% of the variance. Considering the items with factor loads above 0.30, I17, I3, and I14 were observed to have factor loads on multiple factors; however, the difference between these loads was <0.10. Therefore, these statements were eliminated from the scale and a third factor analysis was applied. All 32 remaining items were subjected to obliquely rotated basic components analysis (KMO = 0.938; Bartlett test (496) =13946.204; P < 0.001). As a result of the analysis, a 7-factor structure with 32 items having an eigenvalue above 1 was obtained, explaining 54.59% of the variance. Considering the items with factor loads above 0.30, it was found that I41, I43, and I12 were observed to have factor loads on multiple factors, however the difference between these loads was <0.10. These items were thus removed from the scale and a fourth factor analysis was conducted. All 29 remaining items were subjected to obliquely rotated basic components analysis (KMO = 0.936; Bartlett test (406) =13026.053, P < 0.001). As a result of the analysis, a 6-factor structure with 29 items having an eigenvalue above 1 was obtained, explaining 54.42% of the variance. Considering the items with factor loads above 0.30, it was found that I27 received a load on more than one factor, but the difference between these loads was <0.10. This item was thus deleted from the scale and a fifth factor analysis was performed. All 28 remaining items were subjected to obliquely rotated basic components analysis (KMO = 0.937; Bartlett test (378) = 12825; P < 0.001). As a result of the analysis, a 6-factor structure explaining 55.77% of the variance, comprising 28 items with eigenvalues above 1 was obtained. The final results of obliquely rotated basic components analysis performed for the COVID-19 Phobia Scale are shown in [Table 3]. Logical investigation of item distributions to factors was performed following the obliquely rotated basic components analysis, and I13, I18, and I32 belonging to the first factor; I30 and I9 from the sixth factor were decided to be eliminated from the scale. Moreover, I24 with its loading on the fifth factor was found to be compatible with the statements of the fourth factor; I39 with its loading on the sixth factor along with I36 with its loading on the fifth factor was found to be compatible with the statements of the third factor. These items were thus allocated to related factors for confirmatory factor analysis.
|Table 3: Final obliquely rotated key components analysis applied to COVID-19 Phobia Scale|
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The internal consistency coefficients of the 23 items remaining after exploratory factor analysis based on their final factor distributions are provided in [Table 4].
|Table 4: Internal consistency analyses findings for COVID-19 Phobia Scale|
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The internal coefficients of the scale were found to be crα =0.84 for items in total; crα =0.92 for F1 (worry); crα =0.67 for F3 (reassurance seeking/precaution); and crα =0.60 and F4 (avoidance). It was observed that the internal consistency coefficient decreased with the presence of I24 in the avoidance subscale, and thus, this item was eliminated from the scale before proceeding to confirmatory factor analysis for the remaining 22 items and four subscales. After the elimination of I24 from the scale, the internal consistency coefficients were found to be crα =0.84 for the items in total and crα =0.60 for subscale F4 (avoidance).
Spearman correlation analysis was conducted for the total scale scores and the scores of the Hospital Anxiety and Depression Scale and Health Anxiety Scale for the determination of the scale's criterion validity. Results of the analysis are provided in [Table 5].
|Table 5: Spearman correlation analyses findings between the scores of COVID-19 Phobia Scale and the scores from the Hospital Anxiety and Depression Scale and Health Anxiety Scale|
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A significant positive correlation was found to exist between the total COVID-19 Phobia Scale score and anxiety (r = 0.464; P = 0.000); depression (r = 0.371; P = 0.000); total health anxiety score (r = 0.471; P = 0.000); health anxiety subscales “oversensitivity to physical symptoms” and “anxiety” (r = 0.457; P = 0.000) and “negative outcomes” of health anxiety subscale (r = 0.340; P = 0.000).
A significant positive correlation was found to exist between COVID-19 Phobia Scale Worry Subscale and anxiety (r = 0.568; P = 0.000); depression (r = 0.434; P = 0.000); total health anxiety score (r = 0.531; P = 0.000); health anxiety subscale (r = 0.531; P = 0.000); health anxiety subscales “oversensitivity to physical symptoms” and “anxiety” (r = 0.509; P = 0.000); and “negative outcomes” of health anxiety subscale (r = 0.394; P = 0.000).
A significant negative correlation was found to exist between COVID-19 Phobia Mood subscale and anxiety (r = −0.529; P = 0.000); depression (r = −0.585; P = 0.000); total health anxiety score (r = −0.363; P = 0.000); health anxiety subscale (r = −0.363; P = 0.000); health anxiety subscales “oversensitivity to physical symptoms” and “anxiety” (r = −0.325; P = 0.000); and “negative outcomes” of health anxiety subscale (r = −0.356; P = 0.000).
A significant positive correlation was found to exist between COVID-19 Phobia Scale Reassurance Seeking/Precaution subscale and anxiety (r = 0.371; P = 0.000); depression (r = 0.409; P = 0.000); total health anxiety score (r = 0.416; P = 0.000); health anxiety subscale (r = 0.416; P = 0.000); health anxiety subscales “oversensitivity to physical symptoms” and “anxiety” (r = 0.390; P = 0.000); and “negative outcomes” of health anxiety subscale (r = 0.338; P = 0.000).
A significant positive correlation was found to exist between COVID-19 Phobia Scale Avoidance subscale and anxiety (r = 0.283; P = 0.000); depression (r = 0.287; P = 0.000); total health anxiety score (r = 0.232; P = 0.002); health anxiety subscales “oversensitivity to physical symptoms” and “anxiety” (r = 0.200; P = 0.008); and “negative outcomes” of health anxiety subscale (r = 0.254; P = 0.001).
Depending on the results of correlation analyses for criterion validity, it can be concluded that the COVID-19 Phobia Scale proved for criterion validity.
Confirmatory factor analysis
Investigation of correlation findings revealed a significant positive relationship between COVID-19 Phobia Scale total score and the scores of subscales. Correlation coefficients between the subscales of the COVID-19 Phobia Scale are provided in [Table 6]. The result of confirmatory factor analysis conducted for identifying the measurability of implicit structures of anxiety, mood, reassurance-seeking/precaution, and avoidance parameters used for predicting COVID-19 phobia is depicted in [Figure 1].
|Table 6: Correlation coefficients between the subscales of the COVID-19 Phobia Scale|
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The most commonly used statistical measures for calculating the model-data fit with confirmatory factor analysis are the Chi-square (χ2), χ2/sd, RMSEA, RMR, GFI, and CFI. GFI values <0.85 and RMR and RMSEA values <0.10 are nevertheless considered as the acceptable lower limits for model-data fit., A model-data fit is said to exist whenever the calculated χ2/df ratio is <5, the GFI and CFI values are higher than 0.90, and RMR and RMSEA values lower than 0.05. Goodness of fit results based on the first-order confirmatory structure tested with four latent and 22 indicator variables was found as χ2/sd = 3.899, RMSEA = 0.048, RMR = 0.033, GFI = 0.943, and CFI = 0.942 [Table 7].
|Table 7: Findings of first-order confirmatory factor analysis for COVID-19 phobia scale|
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Comparing the results of CFA with the acceptable fit indices reported in the literature, it was concluded that the model constructed for the theoretical structure of the COVID-19 Phobia Scale complied with the fit indices.
A second-order confirmatory analysis indicating the structural relations of worry, mood, reassurance-seeking/precaution, and avoidance dimensions with the upper dimension of COVID-19 phobia is constructed and depicted in [Figure 2] to prove that these four dimensions obtained by the first-order confirmatory factor analysis for COVID-19 Phobia Scale represented the theoretically suggested COVID-19 phobia.
Goodness of fit results based on testing the second-order factor model constructed with the addition of COVID-19 latent variable to the first-order confirmatory structure tested with four latent and 22 indicator variables were found to be χ2/sd = 3.939, RMSEA = 0.049, RMR = 0.037, GFI = 0.942, and CFI = 0.940 [Table 8].
|Table 8: Findings of second-order confirmatory factor analysis for COVID-19 Phobia Scale|
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Reviewing the results of first-order and second-order factor analyses, it can be stated that the COVID-19 Phobia Scale can be used as a measurement tool to predict COVID-19 phobia, worry, mood, reassurance-seeking/precaution, and avoidance levels.
Discriminative feature of the scale
A 27% upper-lower subgroup comparison was performed to determine the distinctiveness of the COVID-19 Phobia Scale. Independent samples t-test was utilized to determine whether there exists a significant difference between the averages of 27% upper subgroups and 27% lower subgroups. The results are provided in [Table 9].
|Table 9: COVID-19 Phobia Scale lower–upper group means, standard deviations, and independent samples t-test findings|
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Results of the t-test revealed a significant difference between the averages of 27% upper subgroups and 27% lower subgroups of the COVID-19 Phobia Scale (t = −60.484; P = 0.000). This finding suggested that those who scored higher on the COVID-19 Phobia Scale could be differentiated from those who scored low.
| Discussion|| |
As negative emotions such as anxiety, phobia, and fear that arise during a pandemic period adversely affect the behavior of individuals, relevant psychometric measurement tools are needed for determining the risk factors to guide both the individual and social preventive actions during the pandemic. This study aimed to reveal whether the COVID-19 Phobia Scale, which was constructed to evaluate the changes in emotions and behaviors that arise during the COVID-19 pandemic, was a valid and reliable tool. Exploratory and confirmatory factor analyses of the COVID-19 Phobia Scale demonstrated the scale to be valid and reliable, along with the correlation analyses providing the same result. The COVID-19 Phobia Scale, comprising 22 items and four subscales to measure the emotions and behavioral changes observed during the COVID-19 pandemic, was thus shown to be a valid and reliable measurement tool.
The main factor structure was first determined through the utilization of exploratory factor analysis, where the items having lower reliability coefficients were eliminated from the scale and the analysis was repeated to construct the final version of the scale. The lower acceptable limit for the Cronbach's alpha coefficient, indicating the reliability of scales, is accepted to be 0.70 in the literature. The Cronbach's alpha coefficient of the COVID-19 Phobia Scale was found to be 0.84. The scale proved to have a good factor structure concerning total and individual subscales.
A 4-factor scale comprising worry, mood, reassurance-seeking/precaution, and avoidance subscales was obtained as a result of the factor analyses performed with the scale items. The Cronbach's alpha coefficient of the first factor, which was coined as “Worry subscale” that comprised 10 questions including feelings and thoughts, such as thoughts about the disease that arose with the outbreak of the pandemic, worry to be infected with the disease, health, and future concerns, was found to be 0.92. The Cronbach's alpha coefficient value of the first factor, which indicated the severity of the initial emotional reactions that arise following the outbreak and constitute almost half the total number of questions on the scale, is the highest among all factors. The second factor coined as the “Mood subscale” evaluates the depressive mood, comprised three questions on the joy of life, enjoying life, and meaning of life. Research conducted during pandemic suggests that depressive symptoms were the second most observed group of symptoms following the first group of symptoms being anxiety., We believe that the inclusion of depressive symptoms, unlike other scales used for COVID-19 and its psychological effects, would add to the authenticity of our COVID-19 Phobia Scale. The “Reassurance Seeking/Precaution” determined as the third factor comprised seven questions that involved individual measures taken to protect oneself from infection, acquiring information about the infection, and talking to others to feel safe and comfortable. The “Avoidance subscale,” determined as the last factor, comprised two questions involving the avoidance to enter crowded and closed environments. “Avoidance in talking about COVID-19” was also considered to be included in this subscale during the item preparation stage; however, it was observed through analyses that elimination of this item increased the validity of the total and the existing factorial structure. This might be related to the level of trauma experienced by individuals during the process. While some individuals experiencing traumatic symptoms might refrain from talking about COVID-19, other individuals might feel the urge to constantly talk about the subject for alleviating their anxiety levels. This ambivalent situation might have resulted in the increase of the internal consistency coefficient as the 24th item was eliminated from the scale.
Hospital Anxiety and Depression Scale and Health Anxiety Scale were used for determining the criterion validity of the COVID-19 Phobia Scale. Health Anxiety Scale was used for this purpose as the health anxiety was considered to be one of the main factors that determine human behavior during pandemic periods. Because the COVID-19 Phobia Scale measures both anxiety and depression symptoms, the Hospital Anxiety and Depression Scale, where anxiety and depression are evaluated together, was chosen to be another scale to test for criterion validity. Correlation analyses revealed that the total and subscales of the COVID-19 Phobia Scale correlated highly with other scales and that the criterion validity was high.
| Conclusion|| |
The COVID-19 Phobia Scale is found to be a valid and reliable tool that can be used to detect mood changes, such as anxiety and depression in individuals, during the pandemic and the behavioral changes that arise to cope with worry. Our scale is constructed such that it can be used to establish health policies against possible outbreaks in the coming years and is relatively short and accessible online can be counted as one of its advantages.
Despite the high number of participants in the study, one of its limitations was the online introduction method of scales to the participants due to the circumstances of the pandemic. Face-to-face interviews constitute a crucial stage in clinical research, and this could not be performed for this study. Although online face-to-face interviews with participants were considered to be conducted early during the pandemic, it was predicted that the possible biasing effects of online meetings might fail to be controlled. The fact that a re-test could not be conducted due to the pandemic circumstances was yet another limitation of the research. Conversely, likely, re-test results of the participants who adapted more easily to the process might change in the opposite direction as no research on coping with this process has yet been conducted. The lack of a re-test was thus found reasonable, while it also was a limitation of the study. It is noteworthy that the majority of participants were females and had an educational status of an undergraduate degree or above. It was concluded that the online conduction of research facilitated access to individuals with higher educational statuses rather than individuals with lower educational statuses. It might be of use to reassess the scale with participants that have an educational qualification of high school and below.
Patient informed consent
Informed consent was obtained.
Ethics committee approval
The ethics committee approval has been obtained from Üsküdar University Non-Interventional Clinical Research Ethics Committee (61351342/2020-227).
Financial support and sponsorship
No funding was received.
Conflicts of interest
There are no conflicts of interest to declare.
Author contribution area and rate
Nesrin Dilbaz: conception/design of the work, data acquisition, drafting, and its critical revision for important intellectual content (40%).
Cemal Onur Noyan; involved in refining the conception of the work, have given final approval of the version to be published (30%).
Gül Alpar; involved in refining the conception of the work, analysis, and interpretation of data, prepared the figures (15%).
Özlem Kızılkurt Kazan: involved in refining the conception of the work, the interpretation of data for the work, and revising it critically for important intellectual content (15%).
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]