Psychometric Validation of the Fear of COVID-19 Scale (FCV-19S) in a US Academic Health Sciences Center

Round 1

Reviewer 1 Report

Overall, the manuscript is well written, methodologically sound, and provides valuable results.

The comments are in the attached document.

Comments for author File: Comments.pdf

Author Response

Dear Reviewer,

Thank you for your thorough and thoughtful review of our manuscript. We sincerely appreciate the time and expertise you invested in evaluating our work. Your comments substantially strengthened the clarity, rigor, and transparency of the manuscript, and all recommendations have been fully addressed in the revised version. Below, we provide a point-by-point response to each comment.

Comment:
The opening paragraph appropriately positions the pandemic in time and highlights its global impact (morbidity, mortality), but the epidemiological figures reported should be supported by exact, up-to-date WHO or CDC citations.

Response:
We appreciate this recommendation. Explicit, up-to-date citations to the World Health Organization and U.S. Centers for Disease Control and Prevention dashboards and surveillance reports have been added, reflecting the most current data available at the time of revision (Introduction, paragraph 1; refs. 7–8; verified 26 January 2026).

Comment:
The Introduction should build the rationale and clearly formulate the study aim and hypotheses, not announce results in advance.

Response:
We fully agree. The statement prematurely indicating model superiority has been removed from the Introduction and reframed as a theoretical rationale. Results are now presented exclusively in the Results section, and the Introduction focuses solely on background, rationale, and study aims. Hypotheses are now explicitly listed and clearly separated from interpretation.

Comment:
The Abstract reports N = 1,671, whereas the Methods report N = 1,761. Sample size must be harmonized or justified.

Response:
Thank you for identifying this discrepancy. The analytical sample is now consistently reported as N = 1,761 across the Abstract, Methods, Results, and all tables. No cases were excluded from psychometric analyses; this is now explicitly stated in the Methods and Results sections.

Comment:
Repeating full item wording in the Methods is unnecessary given Table 1.

Response:
The Methods section has been streamlined to retain conceptual descriptions of emotional and somatic domains only, with full item wording preserved exclusively in Table 1, as recommended. A clarifying note has been added to Table 1 indicating that the domain structure is theory-driven.

Comment:
The Results incorrectly interpret higher AIC/BIC as improved fit for the two-factor model.

Response:
We appreciate your careful attention to this important issue. The Results text and Table 3 footnotes have been corrected to accurately reflect that lower AIC and BIC values indicate superior model fit. All values are now internally consistent and aligned with the standard model-comparison interpretation (Results Section 3.2; Table 3, footnote 4).

Comment:
The Conclusions include statements that belong to the general literature rather than the empirical findings of this validation study.

Response:
The Conclusions section has been fully revised to be based solely on the study’s psychometric evidence (reliability, factor structure, and construct validity). Broader implications are now explicitly framed as future research considerations rather than direct findings (Section 5).

Once again, we sincerely thank you for your constructive and detailed feedback, which meaningfully improved the manuscript.

With appreciation,
Brandt Wiskur, PhD
Corresponding Author

Reviewer 2 Report

Dear Author(s),
Thank you for submitting your manuscript entitled “Psychometric Validation of the Fear of COVID-19 Scale (FCV-19S) in a US Academic Health Sciences Center” to COVID.

The manuscript evaluates the factor structure and internal consistency of the Fear of COVID-19 Scale (FCV-19S) in a large sample recruited from a U.S. academic health sciences center during the COVID-19 pandemic (2020).
The topic is interesting, the sample size is large, and the comparison between one-factor and two-factor models is appropriate. However, substantial revisions are required before the manuscript can be considered for publication. The main issues concern:
- insufficient justification for the need for a new validation study, given existing English-language validations of the FCV-19S;
- conceptual and methodological ambiguity regarding the target population, particularly the inclusion of faculty and students when the study is framed as a healthcare workforce validation;
- important limitations in methodological transparency and reporting, including factor-analytic procedures and inconsistencies in model-comparison statistics.

ABSTRACT

• The abstract should more clearly acknowledge that the study was conducted within a single academic health sciences center using a convenience sample.
• Key CFA fit indices should be reported consistently for both models, and it should be noted that although the two-factor model improves fit, RMSEA remains above conventional “good fit” thresholds (RMSEA = 0.09).

INTRODUCTION

1. The authors state that the FCV-19S has been validated mainly in “general populations” and not within the U.S. healthcare workforce (lines 56-58). However, the scale has already been validated in English-speaking populations, including student samples, for example: https://doi.org/10.1007/s11469-020-00356-3; https://doi.org/10.1007/s11469-020-00342-9. These studies and previous research should be explicitly discussed. The manuscript currently does not clearly explain why these existing validations are inadequate for the present context.
2. Healthcare workers as a distinct population must be theoretically justified. If the authors argue that healthcare workers constitute a population with unique cultural, occupational, or psychological characteristics that may alter the scale’s psychometric properties, this assumption must be explicitly stated and theoretically supported. Otherwise, the study risks appearing as a replication of an already validated instrument in the same language without a convincing rationale.
3. The Introduction frames the study as a validation in U.S. healthcare workers, yet the sample includes other populations, such as faculty members and students. Faculty members are not necessarily healthcare practitioners, and students are a population for which an English validation already exists (see DOI above). This inconsistency substantially weakens the study's rationale and must be addressed.
4. The Study Aim and Hypotheses are presented as standalone paragraphs but include interpretive statements and anticipation of results (e.g. statements implying superiority of the two-factor model; lines 83-84). Aims should be strictly descriptive. Please revise by clearly separating aims and hypotheses (I suggest using the PICO model) and removing interpretive or result-oriented statements from these sections.
5. While previous studies have suggested a two-factor structure (lines 59-60), it is unclear on what basis the authors hypothesized (hypothesis 2) a priori that this structure would be superior specifically in a U.S. healthcare worker population (lines 87-89). The hypothesis risks appearing post hoc and should be reframed with explicit reference to prior evidence and theoretical assumptions.
6. The first mention of Ahorsu et al. appears in APA style rather than journal style (line 54). Please revise references according to journal guidelines.

MATERIALS AND METHODS

The section should be reorganized into standard subsections: Study design; Participants and sampling; Measures; Procedure; Statistical analysis; Ethical Considerations, to improve readability and transparency.

Sample and data collection procedures

1. The authors report recruiting “students, staff, and faculty” (line 93), yet the manuscript repeatedly frames the study as a validation among healthcare workers. Faculty members are often non-clinical, and US students represent a population for which the FCV-19S has already been validated in English (see https://doi.org/10.1007/s11469-020-00356-3). Therefore, why were these groups included? How do they contribute to the stated aim of validating the scale in healthcare workers? If the authors intend to validate the FCV-19S in a broader academic health campus population, this must be clearly stated and consistently reflected throughout the manuscript. Otherwise, the inclusion criteria and rationale must be revised.
2. The number of responses obtained (lines 97–98) is a result and should be moved to the Results section.
3. Data collection occurred in May–June 2020 (lines 101-102), while IRB approval is reported as March 2021 (line 396). This discrepancy must be clarified (e.g., secondary analysis approval).

Measures

The authors state that 15 additional demographic and health-related questions were included (lines 117-118), but these are not described. For transparency and reproducibility, these variables should be at least briefly listed or provided as supplementary material.

Data analysis

• Reporting of the Exploratory Factor Analysis (EFA) is insufficient. Please report: extraction method, rotation, factor loadings, criteria for factor retention, and any measures of sampling adequacy.
• If EFA and CFA were conducted on the same dataset, this limitation should be acknowledged.
• The CFA estimator and handling of ordinal data must be specified.
• The extensive explanation of fit indices can be substantially shortened (lines 155-180).

RESULTS

1. Table 3 contains apparent errors or inconsistencies regarding AIC and BIC values, which seem reversed between the one-factor and two-factor models. Additionally, the footnote stating that the two-factor model has “higher AIC and BIC” contradicts standard interpretation and the authors’ conclusions. This issue must be corrected, as it directly affects the main findings.
2. While the two-factor model clearly improves fit, RMSEA remains above commonly accepted thresholds. This should be explicitly acknowledged in the Results and Discussion.

DISCUSSION

1. Statements such as “one of the first” (line 339) and “unique focus on healthcare workers” (lines 346-347) are misleading, given existing English validations and the inclusion of non-healthcare groups. These claims should be revised.
2. Conclusions referring exclusively to healthcare workers are not fully supported by the sample composition and should be tempered or reframed.
3. In addition to convenience sampling and single-center design, limitations should explicitly include: heterogeneous sample composition, nonresponse bias, and use of the same dataset for EFA and CFA (if it is the case).

CONCLUSIONS

• The conclusions should be more cautious and reflect the specific context and population actually studied, avoiding overgeneralization to all U.S. healthcare professionals.

OVERALL RECOMMENDATION

Major revision.
While the dataset is large and the topic relevant, the manuscript currently lacks sufficient conceptual justification for a new validation study and suffers from ambiguity regarding the target population and methodological reporting. Addressing these issues is essential before the work can be considered for publication.

I hope these comments are constructive and helpful to the Author(s).

Best regards.

Author Response

Dear Reviewer,

Thank you for your detailed and highly constructive review of our manuscript. Your comments were instrumental in strengthening the conceptual justification, methodological transparency, and interpretive rigor of the study. We are grateful for the care and precision of your feedback, and we have addressed each point in full, as outlined below.

Abstract

Comment:
The abstract should acknowledge single-center convenience sampling and note that RMSEA exceeds conventional thresholds.

Response:
The Abstract now explicitly states that the study was conducted at a single academic health sciences center using a convenience sample. It also notes that although the two-factor model improved overall fit, RMSEA remained above conventional thresholds for close fit (final sentences of Abstract).

Introduction

Comment 1:
Prior English-language validations were not adequately discussed.

Response:
We have added explicit discussion of prior English-language validations conducted in student and community samples (refs. 13–15) and clarified why these contexts do not fully capture populations embedded within healthcare delivery systems (Introduction, paragraphs 4–6).

Comment 2:
Healthcare workers as a distinct population require theoretical justification.

Response:
A dedicated paragraph has been added to provide theoretical justification for conceptualizing healthcare workers and trainees as a distinct occupational–psychological population, drawing on literature addressing exposure risk, moral responsibility, constrained autonomy, and somatic stress (Introduction, paragraph 3; refs. 10–11).

Comment 3:
Mismatch between stated population and actual sample composition.

Response:
We have revised the manuscript to consistently frame the study population as an academic health workforce embedded within a healthcare delivery system, rather than exclusively healthcare workers. This framing is now aligned across the Abstract, Introduction, Methods, Results, Discussion, and Conclusions.

Comment 4:
Study aims and hypotheses contain interpretive language.

Response:
The Study Aim and Hypotheses sections were rewritten to be strictly descriptive and theory-driven, with all anticipatory or result-oriented language removed.

Comment 5:
The two-factor hypothesis appears post hoc.

Response:
The hypothesis is now explicitly grounded in prior international psychometric evidence and occupational stress theory, clarifying the a priori rationale for testing a two-factor structure in healthcare-related populations (Introduction, final paragraphs; refs. 17–19, 23–27).

Comment 6:
Reference style inconsistency for Ahorsu et al.

Response:
All references have been corrected to conform to MDPI journal style throughout the manuscript.

Materials and Methods

Comments:
Structural organization, sampling rationale, IRB timing, psychometric methods, and reporting clarity require revision.

Response:
All requested methodological revisions have been fully implemented:

• The Methods section is reorganized into standard subsections (Study Design; Participants and Sampling; Measures; Procedure; Statistical Analysis; Ethical Considerations).
• Sample size reporting has been moved to the Results section.
• The timing of IRB approval is clarified as secondary analysis approval obtained in March 2021.
• EFA procedures (extraction method, rotation, retention criteria, and sampling adequacy) are fully specified.
• The CFA estimator (WLSMV) and handling of ordinal data are explicitly stated.
• The limitation of conducting EFA and CFA on the same dataset is explicitly acknowledged.
• Explanations of fit indices have been substantially shortened for clarity and concision.

Measures

Comment:
Demographic and health-related variables were not described.

Response:
All additional demographic, occupational, and health-related variables are now listed in Supplementary Table S1, and the Methods section explicitly references this table to ensure transparency and reproducibility (Section 2.3.2).

 

Results

Comments:
AIC/BIC inconsistencies and lack of RMSEA acknowledgment.

Response:
All AIC and BIC values have been corrected and are now consistently interpreted. The elevated RMSEA for the two-factor model is explicitly acknowledged in both the Results and Discussion sections.

Discussion

Comment:
Claims of uniqueness and exclusive focus on healthcare workers are not supported.

Response:
All such language has been removed or appropriately tempered. The Discussion now clearly states that findings apply to a heterogeneous academic health workforce at a single institution, and it avoids overgeneralization.

Conclusions

Comment:
Overgeneralization to all U.S. healthcare professionals.

Response:
The Conclusions section has been revised to explicitly contextualize findings to the study population and institution. Broader implications are now framed as future research needs rather than direct study conclusions.

We sincerely appreciate your careful and rigorous evaluation of our work. Your feedback significantly strengthened the manuscript, and we are grateful for your contribution to its improvement.

With appreciation,
Brandt Wiskur, PhD
Corresponding Author

Reviewer 3 Report

Overall, the study is well executed, but some minor inaccuracies have been identified that need to be rectified prior to the manuscript's publication. Additionally, the Introduction section could be improved by addressing in depth the fear of COVID-19 among faculty, residents/fellows, students, and non-faculty administrative personnel at the Health Campus, as this is a central issue of the presented study.

 

-In the Abstract on page 1, lines 20–21, the following text appears: "among 1,671 healthcare professionals and academic staff at the University of Oklahoma Health Campus". However, according to page 3, line 97, and Table 2, the number of respondents was 1,761.

-The value of the one-factor mode does not fully match between the text and Table 3. Specifically, page 6, line 233 says "CFI (0.89)," but Table 3 shows for One-factor a CFI value of 0.86.

-Figure 2 (page 9) shows item "q4" in factor 1 twice, but item 5 (q5) is not present.

Author Response

Dear Reviewer,

Thank you for your careful review and for highlighting several important issues that improved the accuracy and clarity of our manuscript. We sincerely appreciate your attention to detail. All comments and recommendations have been fully addressed, as outlined below.

Comment 1

Sample size inconsistency (1,671 vs. 1,761).

Response:
This inconsistency has been corrected throughout the manuscript. The final analytical sample is now consistently reported as N = 1,761 in the Abstract, Methods, Results, and all tables.

Comment 2

Mismatch between CFI values reported in the text and Table 3.

Response:
All CFI values have been reviewed and corrected to ensure full internal consistency between the text and Table 3.

Comment 3

Figure 2 shows duplicated item q4 and omits item q5.

Response:
Figure 2 has been corrected to include the appropriate indicator set for each latent factor (emotional fear: q1, q2, q4, q5; somatic fear: q3, q6, q7). The revised figure now accurately reflects the specified model.

Additional Comment: Supplementary Variables

Response:
As requested, all additional demographic, occupational, and health-related variables collected in the original survey but not included in the psychometric modeling are now transparently reported in Supplementary Table S1. These variables were used exclusively for sample characterization and were not analyzed in the present psychometric study. This approach aligns with best practices in psychometric research by maintaining both transparency and analytic focus.

Methods citation (MDPI style):
“Additional demographic, occupational, and health-related variables collected for sample characterization are provided in Supplementary Table S1.”

We appreciate your careful evaluation and constructive recommendations, which substantially improved the manuscript.

With sincere thanks,
Brandt Wiskur, PhD
Corresponding Author

Round 2

Reviewer 2 Report

Dear Author(s),

Thank you for submitting the revised version of your manuscript.

The manuscript has substantially improved compared to the previous version, and I appreciate the thorough manner in which the authors have addressed prior comments and suggestions. The rationale for the study is now clearly articulated, and the inclusion of the different population groups is justified. Overall, the revisions have strengthened the conceptual clarity and methodological transparency of the work.

I appreciated the addition of Table S1, which enhances the transparency and reproducibility of the study. I recommend ensuring that this supplementary material fully adheres to the Journal’s formatting guidelines (e.g., font, layout, and style).

Additionally, the statement regarding Patents is currently presented as a standalone section (n. 6) at the end of the manuscript. Please verify that it conforms to the Journal’s formatting requirements and is reported consistently with the subsequent sections (e.g., Author Contributions, Funding).

Considering these revisions, in my opinion, the manuscript is suitable for publication pending minor checks.

Best regards.