1. Introduction
The psychology of human beings can be shaped by surrounding events such as global infectious threats [
1]. We are vulnerable to struggle from a number of psychological problems during outbreaks such as fear, anxiety, distress and depression. Fear is a normal defensive emotion either innate or acquired [
2]. It consists of a sequence of biological steps to prepare humans for a dreadful incident [
2]. However, excessive or chronic fear can be pathological leading to anxiety, depression and other psychological diseases or boost pre-existing conditions [
3,
4,
5].
Infectious outbreaks have increased in recent decades due to globalization. Recently, a new family of coronavirus has emerged and caused pandemic concerns. A number of respiratory infection cases due to unclear origin were first noticed in Wuhan, China, by the end of 2019 [
6]. As the number of cases increased, China announced in January 2020 that a new strain from coronavirus family is the cause of this illness. It has rapidly spread across China and then to the whole world in a short period of time causing large numbers of morbidity and mortality [
7]. The World Health Organization (WHO, Geneva, Switzerland) declared in February 2020 a new name for the widespread disease caused by 2019-nCoV: coronavirus disease (COVID-19). The International Committee on Taxonomy of Viruses has retitled the formerly tentatively named 2019-nCoV as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2).
According to the World Health Organization (WHO, Geneva, Switzerland), there were more than 177 million confirmed cases of COVID-19 globally with over 3,800,000 death cases by 20 June 2021 [
8]. The number varies in numerous countries with highest cases in Americas, Europe and South-East Asia. The coronavirus signifies a global public health issue which is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [
6]. Fever is the most common symptom associated with COVID-19 followed by cough, dyspnea, myalgia, headache, anosmia and diarrhea [
9].
Infection control and public health measures work together to limit the spread of this infection by implementing many precautions [
10]. The WHO provided infection control guidelines to limit the spread of COVID-19 based on previous knowledge of MERS and SARS management. These measures included enforced social distance by avoiding close contact with other people, frequent hand washing and avoiding interaction with wild animals [
11].
Pandemics due to influenza can impose many psychological stressors such as the threat of self-infection or close ones, separation from family and friends due to isolation, change in daily routine, loss of job, school closure and shortage of food or medicine [
1,
12]. In addition, people were requested to adapt to new social behaviors, such as maintaining physical distance from others, avoid gatherings in groups with their friends, family or work colleagues, and giving up on their usual leisure pursuits [
13]. Home confinement due to COVID-19 had a negative effect on daily routine where all physical activities decreased regardless of its intensity, daily sitting time increased, food consumption and meal patterns were more unhealthy during confinement [
14]. Caring for the infected and diseased individuals in addition to the threat of death of friends or close ones can be stressful during outbreaks. There are also indirect stress sources such as frequent exposure to media news about the outbreak that could raise uncertainty and distress levels [
4,
15,
16,
17]. Among these stressors, there is a concern about the impact of the crisis on public mental health which may lead to various psychological issues such as fear, anxiety, depression and panic disorder [
6].
The nature of SARS-CoV-2 and its rapid transmission amid humans raised global tension due to stigmatization, isolation, economic impact and loss [
18,
19,
20]. Therefore, assessing the presence of excessive fear and the severity of psychological effect of pandemics are essential to assist people in coping with mental problems and eliminate its negative consequences. It is also helpful in understanding possible disruptive or defensive reactions such as stigmatization and non-adherence to rules [
21]. A number of tools were developed to assess the psychological influence of COVID-19 outbreak [
22,
23]. Dr. Jill Ehrenreich-May had developed Fear of Illness and Virus Evaluation scale in English (FIVE), a 35-item self-report measure consisting of four subscales; Fears about Contamination and Illness, Fears about Social Distancing, Behaviors Related to Illness and Virus Fears and Impact of Illness and Virus Fears [
24]. Before using the scale in different demographic populations, it is preferred to assess the psychometric properties of the scale in the target language [
25]. Therefore, the aim of this study was to examine the psychometric properties of the Arabic translated version of FIVE.
4. Discussion
The deleterious impact of infectious pandemics on individuals’ mental health is well documented in the literature [
35,
36]. Assessing psychological influence of health disasters using various validated measuring tools [
20,
37,
38] facilitates understanding how people would encounter and endure global pandemics and facilitates detecting individuals with mental health needs. Therefore, Fear of Illness and Virus Evaluation (FIVE) is a tool that was developed by
Ehrenreich-May (
In preparation) to estimate the severity and the impact of fears of the public during the COVID-19 global outbreak. This tool was translated to Arabic in the present study and reliability qualities, concurrent validity, face validity, exploratory factor analysis and confirmatory factor analysis were evaluated. The overall findings indicated that the Arabic translated version of FIVE for adults is a reliable and valid tool for assessing the severity and the impact of COVID-19 fear among the population of Saudi Arabia.
FIVE consists of 35 items divided into four subscales: Fears about Contamination and Illness, Fears about Social Distancing, Behaviors Related to Illness and Virus Fears and Impact of Illness and Virus Fears. It is a distinguishable tool in being multidimensional and can be useful for multiple purposes as measuring not only fears but behaviors related to fear during the recent pandemic or any other future illnesses.
The conformity between subscales’ items in the current Arabic version of FIVE examined in the present study is comparable to the Arabic Fear of COVID-19 Scale (FCV-19S) [
28]. For instance, the internal consistency of Fears about Contamination and Illness subscale (items 1–9) was 0.89 and Fears about Social Distancing (items 10–19) was 0.91, which are relatively higher than that found in the Arabic FCV-19S [
28] and Spanish FIVE [
24]. The internal consistency of proposed structure of FIVE in Spanish language was α = 0.88 for Fears of Getting Sick from an illness or virus (items 1–4); α = 0.74 for Fears that Others May Get Sick from an illness or virus (items 5–9); α = 0.85 for Fears of Concrete Limitations due to an illness or virus (items 10, 11, 13, 15–17); while the subscale Fears of not being able to meet Basic Needs of subsistence and work due to an illness or virus (items 12, 14, 18, 19) had α = 0.79. The other FIVE subscales were marginally lower than FCV-19S (Behaviors Related to Illness and Virus Fears α = 0.87 and Impact of Illness and Virus Fears α = 0.84). Nevertheless, Cronbach’s alpha of 0.70 or higher is considered as an acceptable reliability [
39].
The inter-item correlation analysis of the presented tool generally revealed a satisfactory internal consistency. The inter-item correlations and corrected item-total correlations between 0.30 and 0.70 suggest medium to strong associations between the items [
40,
41]. However, item 5 “I am afraid my pet might get a bad illness or virus” in Fears about Contamination and Illness subscale had a corrected item-total correlation of
r = 0.36. This relatively lower correlation reflects its incompatibility in measuring the same attribute of this subscale (Fears about Contamination and Illness) [
41]. This finding was further supported by item loading in exploratory factor analysis in which item 5 loaded with Fears of the Impact on Social Life when items 1–35 were included and with Fears of Getting Sick when items 1–19 were included in the analysis. The culture of adopting pets in Saudi Arabia is not widely popular. Therefore, the inclusion of this question in future investigations should be considered based on researchers’ objectives.
Concurrent validity of the present tool indicates positive correlations of FIVE subscales with the Arabic FCV-19S. These findings ascertain that FIVE is credible in assessing the psychological conditions arising from COVID-19. Similarly, FIVE was positively correlated with Hospital Anxiety and Depression Scale [
38]. The correlation coefficient of FIVE with Anxiety subscale was high (
r = 0.83) and moderate with depression subscale (
r = 0.66) in a previous study [
38]. FIVE was also correlated with both depressive symptomatology (PHQ-9) and posttraumatic stress (ITQ) [
24].
Participants ascertained the clearness and easiness of the survey questions and the comprehensiveness of the questionnaire to important aspects of fear from COVID-19. Most of the respondents denied that the questionnaire violated their privacy. However, few felt the opposite, which is in line with the Hospital Anxiety and Depression Scale where authors reflected the possible sensitivity of some items involved in psychological assessment [
27,
40]. This would emphasize the importance of being more sensible during psychological evaluations.
The suggested structure for FIVE in the present study is based on its factor analysis and model fit indices. As a previous study [
24] suggested four domains for items 1–19 (Fears of Getting Sick, Fears that Others May Get Sick, Fears of Concrete Limitations and Fears of not being able to meet the Basic Needs), our findings that were based on a sufficiently larger and sociodemographically different sample obtained a structure (Fears of Getting Sick; items 1–5, Fears that Others Get Sick; items 6–9 and Fears of the Impact on Social Life; items 10–19) that is somewhat different from that proposed in the Spanish version. On the other hand, when items 1–35 were analyzed, the data showed an improved fit in four domains that was slightly different from the one originally set by
Ehrenreich-May. The newly proposed structure included Fears of Getting Sick; items 1–4, Fears that Others Get Sick; items 6–9, Fears of the Impact on Social Life; items 5, 10–19, 34–35 and Behaviors Related to Illness and Virus Fears; items 20–33. The proposed structure of two factors (items 1–9) had the best fit among other structures. Therefore, future intentions to use this tool in its current Arabic format are recommended to select one of the newly proposed structures that best serves their purposes.
The sample used in the present study comprised of 60% females, over 50% Bachelor qualification or higher and more than 90% were Saudi nationals. The mean age of participants was 33.88 years. Other demographic characteristics might have different findings in different populations. Upcoming studies must inspect whether the current Arabic FIVE version attains comparable psychometric properties in larger and randomly selected samples. Sociodemographic factors, such as age and gender, play a role in the perception of fears from illness and viruses; thus, it is recommended to run multi-group invariance tests in the future to examine the differences in perception of FIVE items across different age groups, genders and other sociodemographic characteristics.
The fear of COVID-19 has a positive relationship with anxiety and depression [
19,
20,
38]. In some extreme cases, fear of COVID-19 was associated with suicide attempts [
42,
43]. Social isolation, economic impact, continuous exposure to the intimidating news about the pandemic and uncertainty may increase the level of anxiety, fear and depression [
20,
44]. In addition, the doubts about contracting SARS-CoV-2 could increase fear amongst people [
18]. Therefore, it is advisable to implement targeted prevention and education programs to aid individuals who are or at risk of being overwhelmed by fear from COVID-19 and help such individuals to engage in preventative behaviors [
20,
45].
Although the present study demonstrated that the Arabic version of FIVE is a reliable and valid tool for estimating the severity of fear from COVID-19, it has some limitations. First, the studied participants were from the general population in Saudi Arabia without professional psychological assessment. Consequently, the sensitivity and specificity of FIVE subscales could not be inspected. In addition, the dependence on an online survey and self-report measurement is influenced by social desirability which could underestimate the severity of fear [
40]. Moreover, a convenient sample was used for this study which may affect the generalizability of our findings. The lack of invariance measurement could be another limitation of this paper.
In summary, based on the sampled population, the present study indicates that the adopted Arabic version of FIVE has good internal consistency and reliability. We consider it a suitable tool that can be used in research to assess the severity of fear of COVID-19 or any other virus on Arabic populations.