Development and Validation of the COVID-19 Worries and Fears Scale

De elopmen and Valida ion o he COVID-19 Wo ies and Fea s Scale Es he Cuad ado 1 , 2 *, Alicia A enas 2 , 3 , Manuel Moyano 1 , 2 and Ma ina La Gamma 4 1 Depa men o Psychology, Uni e si y o Co doba, Có doba, Spain, 2 Maimonides Biomedical Resea ch Ins i u e o Co doba (IMIBIC), Co doba, Spain, 3 Depa men o Social Psychology, Uni e sidad de Se illa, Se ille, Spain, 4 Depa men o Psychology, Uni e si y o Flo ence, Flo ence, I aly Objec i es: How indi iduals pe cei e he isk o COVID-19 influences hei men al heal h and p o ec i e beha io s. The e o e, he de elopmen o an ins umen o cap u e COVID- 19- ela ed wo ies and ea s is ele an . This s udy aims o de elop and alida e he CoV- WoFe o measu e COVID-19- ela ed wo ies and ea s. Me hods: An online ques ionnai e was comple ed by 593 pa icipan s du ing Ch is mas 2020 and by 328 pa icipan s du ing Summe 2021, om which 88 pa icipan s o med a longi udinal sample. Resul s: Analyses confi med a obus adjus men o consis ency o e ime and a gende - in a ian bi ac o ial s uc u e. Fac o 1 ep esen ed wo y abou he heal h consequences o COVID-19 and Fac o 2 ep esen ed he pe cei ed physiological symp oms associa ed wi h ea o COVID-19. Cons uc alidi y was e idenced by: he expec ed ela ions be ween he CoV-WoFe and o he heo e ically ela ed cons uc s; he se ial media ing ole o bo h dimensions in he ela ionship ha secu i y alues es ablish wi h p o ec i e beha io s agains COVID-19 and wi h anxie y; and he expec ed gende di e ences in he Co -WoFe. Conclusion: The CoV-WoFe ep esen s a sho , alid, eliable, gende -in a ian ool ha is easy o apply in bo h he heal h p o essional and esea ch con ex o assessCOVID-19- ela ed wo ies and ea s, which a e a iables o ele ance o sp ead o he i us and o men al heal h. Keywo ds: COVID-19, wo ies, ea s, scale de elopmen , anxie y, p o ec i e beha io INTRODUCTION The COVID-19 pandemic has gene a ed a con ex o unce ain y all o e he wo ld [1]. The success o policies o slow down he apid ansmission o he i us elies in pa on accu a e pe cep ions o he isk ac o s [2]. By knowing how indi iduals pe cei e he isk o COVID-19, heal hca e p o ide s and policymake s could design app op ia e p og ams o slow down he pandemic. The e o e, he main aim o his s udy— o de elop and alida e a b ie ins umen o cap u e he COVID-19- ela ed wo ies and ea s ( he COVID-19 Wo ies and Fea s Scale— he COV-WoFe)—seems ele an . THEORY AND COMPONENTS OF COVID RISK PERCEPTION The ela ionship be ween isk pe cep ion and sa e beha io has been s ongly es ablished in he li e a u e on occupa ional heal h and sa e y and public heal h [3]. Di e en heo e ical models o Edi ed by: F anco Mascayano, New Yo k S a e Psychia ic Ins i u e (NYSPI), Uni ed S a es Re iewed by: F anco Mascayano, New Yo k S a e Psychia ic Ins i u e (NYSPI), Uni ed S a es *Co espondence: Es he Cuad ado [email p o ec ed] This O iginal A icle is pa o he IJPH Special Issue “The Impac o he COVID-19 Pandemic on Men al Heal h.” Recei ed: 11 No embe 2021 Accep ed: 16 Decembe 2022 Published: 09 Janua y 2023 Ci a ion: Cuad ado E, A enas A, Moyano M and La Gamma M (2023) De elopmen and Valida ion o he COVID-19 Wo ies and Fea s Scale. In J Public Heal h 67:1604600. doi: 10.3389/ijph.2022.1604600 In J Public Heal h | Owned by SSPH+ | Published by F on ie s Janua y 2023 | Volume 67 | A icle 16046001 In e na ional Jou nal o Public Heal h ORIGINAL ARTICLE published: 09 Janua y 2023 doi: 10.3389/ijph.2022.1604600 cogni i e o ien a ion—such as he Theo y o Reasoned Ac ion [4–6]—ha e ied o desc ibe he p ocess h ough which people ace a isky si ua ion and wha leads hem o adop p e en i e measu es. Fe e e al. [3] de eloped he TRIRISK model o isk pe cep ion in which delibe a i e, a ec i e and expe ien ial componen s a e dis inguished, al hough o he s udies ha e combined he expe ien ial and a ec i e componen in one unique componen [7–9]. In his sense, many s udies concep ualize isk pe cep ion as a bidimensional cons uc , wi h bo h a cogni i e and an a ec i e componen [9,10]. When conside ing he impac on p o ec i e beha io s, se e al s udies ha e shown ha he a ec i e componen — eeling he isk—has g ea e ele ance han he cogni i e componen —analyzing he likelihood o he isk [11]. In ac , in he pandemic con ex , di e en s udies ha e co obo a ed he g ea e ele ance o he wo ies and ea s ela ed o COVID-19 in compa ison o he pe cei ed p obabili y o becoming in ec ed o p edic ing di e en p o ec i e beha io s [9,12,13]. Thus, he de elopmen and alida ion o a scale ha aps in o he a ec i e componen o COVID-19 isk pe cep ion seems o be o ele ance in he pandemic con ex . Du ing a pandemic, many people exhibi ea - and anxie y- ela ed dis ess esponses; howe e , he emo ional aspec o isk pe cep ion has no been su ficien ly explo ed [14]. Thus, we de eloped he CoV-WoFe, co e ing he emo ional dimension o isk [15,16] and ocusing on wo di e en aspec s: (a) wo y abou he heal h consequences o COVID-19 (CoV-Wo), ep esen ing wo y abou ca ching he i us and i s heal h implica ions; and (b) he ea o COVID-19 (CoV-Fe), ep esen ing how indi iduals p esen uncon ollable anxie y and ea ela ed o COVID-19. We posi he hypo hesis (H1) ha he s uc u e o he CoV-WoFe will show wo dimensions (CoV-Wo and CoV-Fe) consis en ly o e ime. Gende Di e ences in COVID-19-Rela ed Wo ies and Fea s Women and men a e di e en ially a ec ed by COVID-19 and he pandemic [17], hus he e is a need o ca y ou COVID-19 s udies om a gende pe spec i e [17,18]. Acco dingly, we will explo e he in a iance o he CoV-WoFe o ensu e he alidi y o he scale o men and women. Mo eo e , many s udies ha e sugges ed ha gende can play a significan ole in isk pe cep ion, wi h women ending o a e isk highe han men [19,20]. The e o e, we would expec women o show highe le els o wo ies and ea s o e COVID-19 han men (H2). COVID-19-Rela ed Wo ies and Fea s O e Time To be e manage he pandemic, unde s anding people’s wo ies and ea s abou he i us o e ime is impo an [21]. Howe e , ew s udies ha e analyzed he a ec i e pa o isk pe cep ion and he ac o s in ol ed longi udinally [9,22]. Wi h he ex emely high in ec ion a e and ela i ely high mo ali y a he end o 2020, indi iduals began wo ying abou COVID-19. Fea also may ha e amplified he pe cep ion o damage i sel , which could ha e influenced eac ions and p o ec i e beha io s o e ime. The e o e, aking a se e al- mon h lapse, i is expec ed ha in pe iods in which he in ec ion a es a e dec easing, and he in o ma ion gi en by he au ho i ies and media is mo e posi i e, he wo ies and ea s o indi iduals should be lowe han in o he pe iods in which he in ec ion a es a e inc easing and he in o ma ion gi en is ala ming (H3). Fac o s Associa ed Wi h COVID-19-Rela ed Wo ies and Fea s E alua ion o he ex e nal alidi y o he CoV-WoFe supposes he assessmen o ela ionships wi h o he cons uc s po en ially ela ed o wo ies and ea s o COVID-19. To hea abou COVID-19 being a cause o dea h is an indi ec expe ience o a COVID-19 haza d ha supposes highe wo y and ea le els [8]. Thus, we expec ha being o knowing people who a e especially ulne able o COVID-19 and knowing lo ed ones who ha e died om COVID-19 will be ac o s ela ed o he wo y and ea o e he disease. Pe sonal alues o ien ed owa d sel -p o ec ion may ha e an impac on how people pe cei e isks. In his sense, people o ien ed owa d sel -p o ec ion, who gi e impo ance o hei secu i y, adop ed mo e p o ec i e beha io s in he pandemic con ex [23,24] o p o ec hemsel es om COVID-19 con agion. Acco dingly, people pa icula ly wo ied abou sel - p o ec ion will pe cei e highe COVID-19 isks. Ano he impo an ac o ela ed o isk pe cep ion in imes o COVID-19 is skep icism. Simila o clima e change and accina ion, skep icism owa ds COVID-19 may ha e consequences o how people pe cei e isk and he in en ion o p o ec hemsel es [25]. Thus, a nega i e ela ionship be ween skep icism ega ding COVID-19 and he CoV-WoFe is expec ed. Risk pe cep ion induces esponses o cope wi h c ises, exe ing significan influence on decisions and beha io s [26] and pu s people in an anxious s a e, lea ing hem o ake p ecau ions such as p o ec i e beha io s o a oid mo e se ious consequences [27]. Mo eo e , as explained ea lie , se e al s udies ha e ound a ela ionship be ween he emo ional componen o isk pe cep ion and p o ec i e beha io s agains COVID-19 [8,9, 12,13]. Thus, we expec o find a posi i e ela ionship be ween he CoV-WoFe and he in en ion o adop p o ec i e beha io s o a oid COVID-19 con agion, and he p o ec i e beha io s hemsel es, and also be ween he CoV-WoFe and anxie y [27]. The e o e, we expec (H4) ha he CoV-WoFe will show ela ionships wi h: (a) di ec expe ience wi h COVID-19 (being o li ing wi h a COVID-19- ulne able pe son and ha ing lo ed ones who ha e died om COVID-19 will be posi i ely ela ed wi h wo ies and ea s o he disease); (b) pe sonal alues o ien ed owa d secu i y (people highly o ien ed owa d secu i y will show ele a ed wo y and ea le els); (c) skep icism (COVID-19-skep ic people will ha e lowe wo y and ea le els); (d) he in en ion o adop p o ec i e beha io s agains COVID-19 and p o ec i e beha io s hemsel es, which will be posi i ely ela ed o wo ies and ea s; and (e) anxie y, which is also expec ed o be posi i ely ela ed o wo ies and ea s o COVID-19. In J Public Heal h | Owned by SSPH+ | Published by F on ie s Janua y 2023 | Volume 67 | A icle 16046002 Cuad ado e al. COVID-19 Wo ies and Fea s Scale As he e is e idence o he ela ionship o pe sonal alues o ien ed owa d secu i y wi h isk pe cep ion [28–30] and wi h p o ec i e beha io s agains COVID-19 [23,24] and anxie y [31], and as he e is e idence o he ela ionship o isk pe cep ion wi h p o ec i e beha io s [26,27] and anxie y [27], we expec ha wo ies and ea s o COVID-19 will media e he ela ionship ha pe sonal alues o ien ed owa d secu i y es ablish wi h p o ec i e beha io s agains COVID-19 (H5a) and anxie y (H5b). METHODS P ocedu e The s udy comp ises wo phases. In Phase 1, an online ques ionnai e was dissemina ed o Spanish esiden s jus be o e Ch is mas, be ween 15 and 22 Decembe 2020, ia he snowball sampling me hod. Du ing his pe iod, COVID-19 cases we e sligh ly inc easing and he Go e nmen and he media we e gi ing ou wo ying in o ma ion ega ding he plausibili y o a ebound in cases o e Ch is mas by appealing o esponsibili y and main enance o he u mos cau ion du ing he holidays. In con as , Phase 2 ook place 6 mon hs la e , be ween 16 May and 6 June 2021, a pe iod in which COVID-19 cases we e sligh ly dec easing and he Go e nmen and he media we e dissemina ing op imis ic in o ma ion ega ding a supposed e u n o nea -no mali y due o he massi e inc ease in people ge ing accina ed in Spain. The s udy was conduc ed in acco dance wi h he Decla a ion o Helsinki [32] and ecei ed he app o al o he e hics commi ee o he Uni e si y o Co doba (Spain) h ough code CEIH-22-4. In bo h phases, be o e comple ing he ques ionnai e, all pa icipan s ga e hei in o med consen . Pa icipan s The ques ionnai e was comple ed by 593 pa icipan s (64.8% women; age ange = 18–80 yea s, M=42.52,SD =13.82)inPhase1andby 328 pa icipan s (51.8% women; age ange = 15–89 yea s, M= 36.95, SD = 15.53) in Phase 2. In Phase 2, 89 o he 328 pa icipan s we e he same as in Phase 1, o ming a longi udinal sample (63% women; age ange = 18–69 yea s, M=44.71;SD = 11.69). Fu he de ails a e gi en in Supplemen a y Table S1. Measu es The ollowing measu es we e used (C onbach’s alpha alues a e shown in Table 1) and all ac o s we e a ed on a se en-poin Like scale whe e 1 = “S ongly disag ee”and 7 = “To ally ag ee.” No missing da a we e obse ed, excep in he in en ion o adop p o ec i e beha io s ela ed o COVID-19 ansmission. In his case, he missing da a we e eplaced by he mean o he confi ma o y ac o ial analyses (CFA) and mul ig oup CFA (MGCFA) pe o med. The COVID-19-Rela ed Wo ies and Fea s Scale (CoV-WoFe) A sho scale was c ea ed by ocusing on wo di e en expec ed ac o s [1]: CoV-Wo—wo y abou ca ching he i us and he pe cei ed heal h implica ions o he COVID-19 consequences; and [2] CoV-Fe— he ex en o which indi iduals eel a aid abou ge ing COVID-19 by showing uncon ollable physiological symp oms o ea and anxie y associa ed wi h COVID-19. The CoV-WoFe (see Supplemen a y Table S2) was based on he Fea o COVID-19 Scale (FCV-19S) [15] and he dange and con amina ion ea s ac o s o he COVID S ess Scales (CSS) [16]. As i can be obse ed on Supplemen a y Table S2, he ou I ems expec ed o con o m he CoV-Wo we e designed by adap ing in o Spanish some I ems o he CSS [16]. Mo eo e , he ou I ems expec ed o con o m he CoV-Fe we e designed by adap ing in o Spanish some I ems o he FCV-19S [15]. The esul an scale consis ed o eigh i ems: ou expec ed o load in CoV-Wo and ou in CoV-Fe. Di ec Expe ience Wi h COVID-19 Pa icipan s we e asked whe he hey o someone who li es wi h hem has a disease ha makes hem especially ulne able o TABLE 1 | Co ela ions, means, s anda d de ia ions and C onbach’s alpha alues o he s udied a iables in each da a collec ion (S udy A i udes, beha io s, and psychological heal h in ime o pandemic, Spain, 2021). 1 2 3 4 5 6 7 8 9 10 Mean SD α 1. CoV-WoFe —0.86*** 0.89*** 0.15*** 0.16*** −0.20*** 0.52*** 0.26*** 0.35*** —3.99 1.43 0.87 2. CoV-Wo 0.88*** —0.52*** 0.15*** 0.15*** -0.26*** 0.57*** 0.29*** 0.43*** —5.37 1.55 0.86 3. CoV-Fe 0.84*** 0.48*** —0.12** 0.13** -0.09* 0.35*** 0.16** 0.19*** —2.61 1.73 0.89 4. Vulne able o COVID-19 0.12* 0.15** 0.05 —0.12** −0.10* 0.06 −0.05 0.03 ———— 5. Dea h om COVID-19 0.10 0.07 0.11* 0.09 —−0.09* 0.09* 0.12* 0.05 ———— 6. Skep icism ————— —−0.22*** −0.22*** −0.21*** —2.15 1.36 0.90 7. Secu i y SVO ————— — —0.35*** 0.52*** —5.60 1.36 0.79 8. Beha io al in en ion 0.35*** 0.42*** 0.16** 0.03 -0.11* ———0.54*** —4.05 1.38 0.82 9. P o ec i e beha io 0.42*** 0.54*** 0.17** 0.10 -0.09 ——0.61*** ——5.64 1.44 0.94 10. Anxie y 0.29*** 0.14** 0.38*** 0.06 0.10 ——−0.04 −0.01 ———— Mean 3.63 4.85 2.41 —— — — 4.24 5.21 2.97 ——— SD 1.46 1.79 1.59 —— — — 1.32 1.63 0.98 ——— C onbach’s alpha (α)0.87 0.89- 0.86 —— — — 0.81 0.94 0.86 ——— No e: ***p<0.001, **p<0.01, *p<0.05. Uppe iangle alues (in bold) a e o he Ch is mas sample (fi s phase), and lowe iangle alues (in i alic) a e o he Summe sample (second phase); CoV-WoFe, COVID-19 Wo ies and Fea s Scale; CoV-Wo, COVID-19- ela ed wo ies o heal h; CoV-Fe, sel - epo ed physiological symp oms associa ed wi h ea ; SVO, social alue o ien a ion. In J Public Heal h | Owned by SSPH+ | Published by F on ie s Janua y 2023 | Volume 67 | A icle 16046003 Cuad ado e al. COVID-19 Wo ies and Fea s Scale COVID-19 and whe he hey had los a pe son close o him/he who has died due o COVID-19. O ien a ion o Sel -P o ec ion In he fi s da a collec ion, o measu e o wha ex en pa icipan s had pe sonal alues o ien ed owa d sel -p o ec ion, hey esponded o h ee i ems o he secu i y ac o o he Po ai Values Ques ionnai e [33]. Skep icism In he fi s da a collec ion, o measu e skep icism owa ds he disease and he pandemic, a six-i em ad hoc scale (see Supplemen a y Table S3) was designed by adap ing o he pandemic si ua ion and expanding he scale o skep icism owa ds clima e change [34]. Pa icipan s indica ed he deg ee o which hey we e skep ical abou he disease and he pandemic. Explo a o y ac o analysis e ained one unique ac o ha explains 67.44% o he a iance. In en ion o Adop P o ec i e Beha io s Rela ed o COVID-19 T ansmission In bo h phases, in en ion o adop p o ec i e beha io s o p e en COVID-19 ansmission was measu ed wi h he P o ec i e Beha io al In en ion agains COVID Scale [23]. Pa icipan s indica ed o wha ex en hey had he in en ion o pe o m di e en p o ec i e beha io s o p e en i us ansmission in hei amily ga he ings (lunches and dinne s) du ing he nex Ch is mas pe iod o he fi s sample (phase 1) and in hei amily and iends’ga he ings du ing he nex Summe aca ion o he second sample (phase 2). P o ec i e beha io s In bo h phases, o measu e o wha ex en pa icipan s adop ed p o ec i e beha io s o p e en COVID-19 ansmission, hey comple ed he P o ec i e Beha io agains COVID Scale [23]. Anxie y On he second da a collec ion, anxie y was measu ed h ough he anxie y ac o o he alida ed Spanish e sion o he Hospi al Anxie y and Dep ession Scale [35]. S a is ical Analyses The phase 1 sample was andomly di ided in o wo samples o he same size. Wi h he fi s spli sample we explo ed he psychome ic p ope ies o he i ems o assess hei sui abili y o inclusion in u he analysis. Explo a o y ac o analysis (EFA) wi h Oblimin di ec o a ion was pe o med wi h he fi s spli sample and CFA wi h he second spli sample [36]. To explo e he consis ency o he expec ed bi ac o ial s uc u e o e ime, CFA was also pe o med wi h he phase 2 sample. The ex e nal alidi y o he CoV-WoFe was explo ed by assessing he co ela ion o he scale and i s ac o s wi h o he heo e ically ela ed psychosocial a iables o he phases 1 and 2 samples. Mo eo e , wi h he longi udinal sample, media ion analyses we e pe o med using he six h model o he P ocess o SPSS mac o (Hayes, 2013), wi h a confidence in e al o 95% and esampling wi h 10,000 boo s ap samples; secu i y o ien a ion (Time 1) was in oduced as he independen a iable, CoV-Wo and CoV-Fe (Time 2) as se ial media ing a iables and p o ec i e beha io s agains COVID-19 and anxie y (Time 2) as dependen a iables. Gende in a iance was explo ed h ough MGCFA using he la ge phase 1 sample. The goodness-o -fi indices (CFI, TLI and RMSEA) we e assessed using he ules o humb ecommended by Sche melleh-Engel e al. [37]and he cul u e in a iance was assessed by ΔCFI in deciding he bes -fi ing model, assuming ha ΔCFI >0.01 indica es a eliable di e ence be ween he fi ing o cons ained and uncons ained models. Again, wi h he la ge phase 1 sample, he po en ial di e ences be ween men and women in he scale and i s subdimensions we e obse ed h ough analysis o a iance (ANOVA). Finally, e olu ion o he scale and i s subdimensions was explo ed h ough epea ed- measu es analysis (RMA) wi h he longi udinal sample. RESULTS Phase 1: Reducing and Refining he I ems Reliabili y Analyses and Co ela ions The eliabili y le el was high o he CoV-WoFe (α=.86)and o each one o i s wo expec ed ac o s (α CoV-Wo =.86;α CoV- Fe = 0.85). No i ems showed low i em- o- o al co ela ion o dec eased C onbach’s alpha i emo ed. Mo eo e , no i em displayed poo co ela ion wi h hal (o mo e) o he o he i ems in he scale o in he ac o hey we e expec ed o load; ne e heless, i ems 2 and 3 displayed poo co ela ion wi h all he i ems o he expec ed ea ac o o he scale (CoV-Fe). The e o e, i ems 2 and 3 we e emo ed due o a poo co ela ion wi h all he i ems o he second expec ed ac o o he scale. This could be due o he subjec o bo h i ems. While all he o he i ems e e ed o he wo ies o he impac o COVID-19 on one’s own heal h, i ems 2 and 3 e e ed o he impac o lo ed ones. Once i ems 2 and 3 we e dele ed, he eliabili y le el emained high o he CoV-WoFe (α=0.85) and o he ea ac o CoV-Wo (α=0.81). Explo a o y Fac o Analysis EFA showed he wo expec ed ac o s wi h a balanced ac o ial s uc u e (Supplemen a y Table S4) ha explained 77.99% o he a iance, hus confi ming H1. Fac o 1 co esponded o CoV-Fe and Fac o 2 o CoV-Wo. All he i ems loaded in he expec ed ac o s, excep o i em 5, which finally loaded in Fac o 2. Phase 2: Validi y, Reliabili y and In a iance o he Scale Confi ma o y Fac o Analyses When pe o ming CFA by in oducing he bidimensional model ound in EFA, good o excellen fi indices eme ged wi h bo h he second spli sample o he phase 1 sample and he phase 2 sample (Figu e 1). The e o e, consis ency h oughou ime o he expec ed bi ac o ial s uc u e o he CoV-WoFe was confi med, gi ing addi ional suppo o H1. In J Public Heal h | Owned by SSPH+ | Published by F on ie s Janua y 2023 | Volume 67 | A icle 16046004 Cuad ado e al. COVID-19 Wo ies and Fea s Scale Gende Pe spec i e As shown in Table 2, heMGCFA esul sshowed me ic and scala in a iance be ween men and women, demons a ing ha he bi- ac o ial scale was in a ian o gende and alid o bo h men and women. ANOVA (Figu e 2) showed significan di e ences be ween men and women in he gene al CoV-WoFe [F(1,592) = 25.484, p<0.001] and in CoV-Wo [F(1,592) = 13.459, p<0.001] and CoV-Fe [F(1,592) = 25.187, p<0.001], hus confi ming H2. FIGURE 1 | Confi ma o y ac o analyses o he COVID-19 Wo ies and Fea s Scale (S udy A i udes, beha io s, and psychological heal h in ime o pandemic, Spain, 2021). (A) Confi ma o y ac o analysis wi h he second Spli sample o he Phase 1 sample. (B) Confi ma o y ac o analysis wi h he Phase 2 sample. In J Public Heal h | Owned by SSPH+ | Published by F on ie s Janua y 2023 | Volume 67 | A icle 16046005 Cuad ado e al. COVID-19 Wo ies and Fea s Scale Time Pe spec i e RMA (Figu e 3)showedsignifican di e ences be ween he fi s and he second e alua ion ime in he CoV-WoFe [F(1, 88) = 7.06, p< 0.01; ɳ 2 = 0.07, obse ed powe (OP) = 0.75] and in CoV-Fe [F(1, 88) = 11.25, p<0.001; ɳ 2 =0.11,OP=0.91].Nodi e enceswe e ound in CoV-Wo [F(1, 88) = 0.67, ns;ɳ 2 = 0.01, OP = 0.13]. Ex e nal Validi y The expec ed co ela ions be ween he CoV-WoFe (and i s subscales) and he o he explo ed a iables a e displayed in Table 1, showing ha H4 was pa ially suppo ed. The media ion analyses (Table 3)confi med H5a and H5b: ha bo h ac o s o he CoV-WoFe media ed he ela ionship ha TABLE 2 | Goodness-o -fi indices o he mul ig oup confi ma o y ac o analysis (S udy A i udes, beha io s, and psychological heal h in ime o pandemic, Spain, 2021). χ 2 D CFI TLI RMSEA RMSEA [90% CI] SRMR ΔCFI Δχ 2 Configu a ional model 25.326* 12 0.993 0.982 0.043 [0.019; .067] 0.008 Me ic In a iance 29.960* 16 0.992 0.986 0.038 [0.016; .059] 0.017 0.001 4.634 (ns) Scala In a iance 42.886** 20 0.987 0.981 0.044 [0.026; .062] 0.016 0.005 12.926* No e. χ 2 ,chi-squa e es o model fi ; d , deg ee o eedom; CFI, compa a i e fi index; TLI, Tucke -Lewis index; RMSEA, oo mean squa e e o o app oxima ion; SRMR, s anda dized oo mean squa e esidual; ΔCFI, di e ence be ween he CFI alues o wo models ( he es ed model minus he baseline model); Δχ 2 , di e ence in χ 2 es ima es ( he es ed model minus he baseline model); **p<0.01, *p<0.05. FIGURE 2 | Mean di e ences be ween men and women on he COVID-19 Wo ies and Fea s Scale and i s subdimensions (S udy A i udes, beha io s, and psychological heal h in ime o pandemic, Spain, 2021). FIGURE 3 | Mean and s anda d e o o he COVID-19 Wo ies and Fea s Scale and i s subdimensions in each e alua ion phase (S udy A i udes, beha io s, and psychological heal h in ime o pandemic, Spain, 2021). In J Public Heal h | Owned by SSPH+ | Published by F on ie s Janua y 2023 | Volume 67 | A icle 16046006 Cuad ado e al. COVID-19 Wo ies and Fea s Scale secu i y o ien a ion es ablished wi h COVID-19-p o ec i e beha io s and anxie y. DISCUSSION This s udy se ou o cons uc and alida e he CoV-WoFe as a sho and easy- o-apply gende -in a ian ool wi h op imal psychome ic p ope ies o measu e wo di e en ac o s ela ed o he a ec i e dimension o COVID-19 isk pe cep ion: wo ies abou he heal h consequences associa ed wi h COVID-19 (CoV-Wo) and pe cep ion o physiological symp oms associa ed wi h he ea o COVID-19 (CoV-Fe). I s de elopmen was based on o he p e ious la ge bu sligh ly di e en ins umen s [15,16]. The esul s suppo ed a bidimensional s uc u e wi h excellen fi indices ha was consis en o e ime, cohe en wi h he ini ial heo e ical app oach. The ele ance o he CoV-WoFe elies on he possibili y o measu ing hese wo dimensions oge he in a b ie six-i em easy- o-apply ins umen , in con as o p e ious in e es ing bu la ge scales ha measu e only one o hese aspec s. The in e nal consis ency indica o s e alua ed a e op imal, suppo ing bo h he use o he wo ac o s sepa a ely o join ly. Ex e nal Validi y o he CoV-WoFe Cohe en ela ionships be ween he CoV-WoFe (and i s dimensions) and o he a iables o i s nomological ne wo k we e ound, gi ing suppo o he ex e nal alidi y o he CoV-WoFe. Pe sonal Expe ience Rela ed o COVID-19 Di ec and indi ec expe iences o COVID-19 a e ac o s ha influence COVID-19- ela ed wo ies and ea s [8]. To know a close pe son who has died om COVID-19 supposes an inc ease o bo h CoV-Wo and CoV-Fe. Ne e heless, such an expe ience was posi i ely ela ed o CoV-Wo only in he Ch is mas pe iod (phase 1), in which he social con ex was iskie (inc easing in ec ion and dea h a es) and accompanied by au ho i ies’ cau iona y messages ela ed o sel -p o ec ion and sel - isola ion. Non-e heless, in he second phase, du ing he Summe pe iod—cha ac e ized by dec easing in ec ion a es and au ho i ies’ eassu ing messages— he di ec expe ience o ha ing lo ed someone who has died om COVID-19 s ill influences CoV-Fe bu no CoV-Wo. This seems logical: e en in a less isky pe iod, he auma ic expe ience o losing lo ed ones om COVID-19 may s ill exace ba e he mo e uncon ollable physiological symp oms associa ed wi h ea and anxie y. Ne e heless, gene al wo ies abou he heal h consequences o COVID-19 may be mo e dependen on he heal h con ex o he pandemic si ua ion. In he same way, CoV-WoFe and CoV-Wo we e consis en ly associa ed wi h being pa icula ly ulne able o COVID-19 o li ing wi h someone who was pa icula ly ulne able o i . This ela ion is cohe en wi h he heo e ical expec a ion, as pa icula ly isky heal h si ua ions o indi iduals o hei lo ed ones a e ine i ably associa ed wi h inc eases in he wo y o e he heal h consequences o COVID-19. Ne e heless, CoV-Fe was associa ed wi h his a iable only in he Ch is mas sample (fi s phase). These da a could be cohe en , conside ing he con ex o he Ch is mas pe iod, wi h inc easing COVID-19 in ec ion and dea h a es and a social communica ion se ing o ien ed o pe suade people o main ain p ecau iona y measu es and es ic amily ga he ings; such ac o s could pa icula ly inc ease ea and anxie y ega ding COVID-19 and he TABLE 3 | Resul s o he media ion analyses (S udy A i udes, beha io s, and psychological heal h in ime o pandemic, Spain, 2021). P o ec i e beha io s as dependen a iable (H5a) Co -Wo(M1) Co -Fe (M2) P o ec i e beha io (Y) Coe . Sd Coe . sd Coe . sds Secu i y SVO (X) 0.50*** 0.10 −0.01 0.11 0.14 0.07 CoV-Wo (M1) ——0.51*** 0.10 0.43** 0.07 CoV-Fe (M2) ————−0.06 0.07 Model summa y R 2 = 0.25 R 2 = 0.26 R 2 = 0.24 F(1, 87) = 28.57*** F(2, 86) = 14.73*** F(3, 85) = 8.75*** S anda dized indi ec e ec X→M1→YX→M2→YX→M1→M2→Y Boo s app (95% CI) 0.212 [0.067, .390] 0.001[−0.022, 023] −0.015[−0.074, 0.030] Anxie y as dependen a iable (H5b) CoRPS-8 F1 (M1) CoRPS-8 F2 (M2) Anxie y (Y) Coe . Sd Coe . sd Coe . sds Secu i y SVO (X) 0.50*** 0.10 −0.01 0.11 0.18 0.07 CoW (M1) ——0.51*** 0.10 −0.09 0.07 CoF (M2) ————0.55*** 0.07 Model summa y R 2 = 0.25 R 2 = 0.26 R 2 = 0.33 F(1, 87) = 28.57*** F(2, 86) = 14.73*** F(3, 85) = 14.05*** S anda dized indi ec e ec X→M1→YX→M2→YX→M1→M2→Y Boo s app (95% IC) −0.042 [−0.180, .067] −0.005 [−0.123, 0.085] 0.141 [0.060, 0.258] No e: CoV-WoFe, COVID-19 Wo ies and Fea s Scale; CoV-Wo, COVID-19- ela ed wo ies o heal h; CoV-Fe, sel - epo ed physiological symp oms associa ed wi h ea ; SVO, social alue o ien a ion; X, dependen a iable; M, media o ; Y, independen a iable; CI, confidence in e al; Coe ., coe ficien ; SD, s anda d de ia ion. In J Public Heal h | Owned by SSPH+ | Published by F on ie s Janua y 2023 | Volume 67 | A icle 16046007 Cuad ado e al. COVID-19 Wo ies and Fea s Scale associa ed physiological symp oms in people who a e (o li e wi h someone who is) pa icula ly ulne able o COVID-19. Ne e heless, in he second phase, du ing he Summe pe iod (wi h dec easing in ec ion and dea h a es, inc easing accina ion a e and media communica ions ansmi ing confidence abou he end o he heal h c isis in Spain), he associa ion be ween being o knowing someone pa icula ly ulne able o COVID-19 and uncon ollable psychological symp oms ela ed o ea is no so p ominen . Belie s and Values Cohe en wi h p e ious li e a u e showing ha social alue o ien a ion is ele an in shaping isk pe cep ion [2,29,30], he mo e indi iduals we e o ien ed o secu i y, he mo e hey we e wo ied abou he po en ial heal h consequences o COVID- 19 and he mo e hey epo ed physiological symp oms associa ed wi h ea o COVID-19. These ela ions gi e suppo o he ex e nal alidi y o he scale: high COVID-19 wo ies and ea s in people wi h high pe sonal secu i y alues a e cohe en wi h hei sel -p o ec i e o ien a ion [33]. Mo eo e , cong uen wi h p e ious esea ch [25], he mo e indi iduals p esen ed ele a ed sco es on skep icism ega ding COVID-19, he lowe we e hei CoV-Wo and CoV-Fe le els. Clea ly, o people who deny he exis ence and i ulence o COVID-19, o be wo ied abou i s possible consequences and o su e physiological symp oms ela ed o ea makes no sense. P o ec i e In en ions and Beha io s Cong uen wi h p e ious esea ch in he pandemic con ex [38], indi iduals wi h highe COVID-19- ela ed wo ies and ea s, who we e especially wo ied abou he po en ial COVID-19 heal h consequences (CoV-Wo) and epo mo e physiological symp oms ela ed o ea associa ed wi h COVID-19 (CoV-Fe), p esen ed highe in en ions o p o ec hemsel es om COVID- 19 con agion and adop ed mo e COVID-19- ela ed p o ec i e beha io s. Anxie y P e ious esea ch has demons a ed ha anxious indi iduals o e es ima e he p obabili y o nega i e e en s and a e p one o pe cei e mo e subjec i e isks o u u e e en s [39]; bu also, he pe cep ion o high isk will inc ease anxie y by ac i a ing an anxie y s a e [27,40]. In he pandemic con ex , i has been demons a ed ha he mo e indi iduals pe cei e he COVID- 19 si ua ion as isky, he mo e hey eel anxious [16]. In ou esea ch, he CoV-WoFe and i s wo subdimensions we e posi i ely associa ed wi h anxie y. The mo e indi iduals pe cei e high heal h- ela ed isk associa ed wi h COVID-19 and he mo e hey pe cei e symp oms ela ed o ea , hen he mo e hey eel anxious (H4e). Mo eo e , he ac o o he CoV- WoFe ha highly co ela ed wi h anxie y was he ea componen . Gi en ha anxie y symp oms a e ela ed o soma ic s a es ha a e e e enced in he symp oms ela ed o he ea ac o o he CoV-WoFe, his highe associa ion wi h anxie y o CoV-Fe in compa ison wi h CoV-Wo gi es addi ional e idence o he bi ac o ial s uc u e o he scale. Media ing Role o he COVID-19-Rela ed Wo ies and Fea s Cong uen wi h he p e ious li e a u e [23,24,26–31] and wi h ou expec a ion, bo h CoV-Wo and CoV-Fe ac ed as se ial media o s in he ela ionship ha sel -p o ec ion alues es ablish wi h bo h he COVID-19-p o ec i e beha io (H5a) and anxie y (H5b). This esul highligh s he pe cep ual aspec o isk as a undamen al elemen in he adop ion o p o ec i e beha io s, as well as in subjec i e pe cei ed heal h, and has ele an applied implica ions ega ding he communica ion p o ided o people du ing he pandemic: an accu a e communica ion adap ed o he si ua ion ha eflec s he eal isk o he pandemic s a e is necessa y o people o adop he app op ia e sel -p o ec i e beha io s; mo eo e , he app op ia eness and adjus men o he isk communica ion is also ele an , as o e es ima ed isk communica ion could inc ease he anxie y le els o he popula ion, which ha e been significan ly inc eased al eady as a consequence o he pandemic si ua ion [41]. Gende Pe spec i e The CoV-WoFe has been shown o be gende -in a ian , highligh ing he possibili y o using i o bo h gende s in he esea ch and p o essional fields, wi h alid esul s. Mo eo e , i esponds o he need o conduc esea ch in he COVID-19 field om a gende pe spec i e [17]. When analyzing he sco es o men and women, significan di e ences we e ound. Women sco ed highe on isk pe cep ion in gene al and in each one o he wo obse ed dimensions (H2), cong uen wi h p e ious esea ch [19,20], p o iding addi ional e idence o he alidi y o he cons uc . These gende di e ences a e pa icula ly ele an i we conside ha o e es ima ion o he isk o COVID-19 could suppose highe anxie y le els, which is he case in women du ing he pandemic [42–45], he e o e psychological in e en ions o ien ed o dec ease COVID-19- ela ed anxie y le els should conside he isk pe cep ion le el o women in pa icula . Time Pe spec i e Significan di e ences we e ound be ween he fi s and second e alua ion pe iods in he CoV-WoFe and in he pe cei ed isk o heal h(CoV-Wo),wi hlowe le elso COVID-19 isk pe cep ion in he second e alua ion pe iod (Summe ). These esul s a e cong uen wi h he expec a ion ha COVID-19- ela ed wo ies will be lowe in a pe iod in which he in ec ion and dea h a es a e dec easing and he isk communica ion om au ho i ies and media is eassu ing and op imis ic (H5). Thus, he ac ha CoV-Wo is highe in he fi s phase (Ch is mas) is consis en wi h he eal isk and ha in o med by he au ho i ies and media, conside ing he con agion a es and he concu en heal h ci cums ances. Ne e heless, no di e ences we e ound in CoV-Fe, which sugges s ha he physiological aspec s associa ed wi h ea may be less con ex dependen and mo e ancho ed in indi idual a iables. In J Public Heal h | Owned by SSPH+ | Published by F on ie s Janua y 2023 | Volume 67 | A icle 16046008 Cuad ado e al. COVID-19 Wo ies and Fea s Scale Limi a ions and Fu u e Resea ch Among he possible limi a ions o his esea ch a e he sampling me hod and he small sample size o he longi udinal s udy. Mo eo e , all he a iables we e no included in bo h measu emen imes. This p ecludes he possibili y o cla i ying ecip ocal influences be ween inde e mina e and de e mined a iables. Gi en his limi a ion and he limi ed sample size, i was no possible o pe o m a c oss-lagged panel model. Fu u e esea ch should eplica e he ela ionships ound in he p esen s udy wi h a la ge sample size and a mo e powe ul c oss-lagged panel model. Ano he limi a ion conce ns he analyses and findings esul ing om he longi udinal da a. The le el o expe imen al dea h was e y high. Mo eo e , some di e ences we e ound in ce ain a iables: in compa ison o pa icipan s who decided o d op ou o he s udy, pa icipan s who decided o con inue in he second measu emen phase showed lowe le els o CoV-Fe and skep icism and highe le els o p o ec i e beha io in he fi s measu emen phase (bu no di e ences we e ound in CoV-Wo, secu i y o ien a ion o in en ion o adop p o ec i e beha io ). Al hough he di e ences ound a e cong uen —because people who eel mo e engaged in a s udy abou COVID-19 could be people who pe cei e ha his illness exis s (wi h a lowe le el o skep icism) and hus engage in p o ec ion, bu hey could also be people who do no exp ess anxie y symp oms when hinking abou his illness (CoV-Fe)— his can be a p oblem ega ding gene aliza ion o he esul s ha use longi udinal da a. In his sense, he esul s o he media ional analyses should be aken wi h p ecau ion, as he longi udinal sample is p one o selec ion bias. In his ega d, u u e esea ch should eplica e he findings on media ion esul ing om he analyses pe o med wi h he longi udinal da a o he p esen s udy. In u u e esea ch, i would be con enien o con inue in es iga ing he ela ionships be ween eal and pe cei ed isk and he con ibu ing ac o s. I could also be in e es ing o adap his b ie scale o o he ex eme si ua ions o ca as ophes, o be used as a e sa ile measu e in o he ypes o c i ical scena ios. Conclusion A b ie , eliable, gende -in a ian bidimensional scale ( he CoV- WoFe) applicable in di e en samples and scena ios was alida ed. The wo dimensions eflec ed he wo y associa ed wi h COVID-19 heal h consequences (Fac o 1) and he sel -pe cei ed physiological symp oms associa ed wi h ea (Fac o 2). The in e nal consis ency and alidi y indica o s sugges ha his is a e y sho , op imal ins umen ha can be used in heal h and psychosocial esea ch wi h su ficien psychome ic gua an ees o bo h gende s. ETHICS STATEMENT The s udies in ol ing human pa icipan s we e e iewed and app o ed by E hic Commi ee o he Uni e si y o Co doba h ough code CEIH.22.4. The pa ien s/pa icipan s p o ided hei w i en in o med consen o pa icipa e in his s udy. AUTHOR CONTRIBUTIONS EC has concei ed and designed he s udy; analyzed and in e p e ed he da a; w i en he pape ; and supe ised he s udy. She has ull access o all he da a and ake esponsibili y o he in eg i y o he da a and he accu acy o he da a analysis. AA has ac i ely aken pa in he edac ion o he manusc ip and in he in e p e a ion o he da a, and has helped o collec he da a. MM has ac i ely aken pa in he edac ion o he manusc ip and in he in e p e a ion o he da a, and has helped o collec he da a. MG has ac i ely aken pa in he edac ion o he manusc ip and in he in e p e a ion o he da a. FUNDING The da a collec ion was financially suppo ed by he Uni e si y o Co doba, in he Ucoimpulsa modali y o he Own Resea ch Plan o he Uni e si y o Co doba, in which EC is he main esea che . CONFLICT OF INTEREST The au ho s decla e ha hey do no ha e any conflic s o in e es . SUPPLEMENTARY MATERIAL The Supplemen a y Ma e ial o his a icle can be ound online a : h ps://www.ssph-jou nal.o g/a icles/10.3389/ijph.2022.1604600/ ull#supplemen a y-ma e ial REFERENCES 1. Tisdell CA. Economic, Social and Poli ical Issues Raised by he COVID- 19 Pandemic. Econ Anal Pol (2020) 68:17–28. doi:10.1016/j.eap.2020. 08.002 2. 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PLoS One (2022) 17(1):e0262197. doi:10.1371/ jou nal.pone.0262197 8. Sa ado i L, Lau iola M. Risk Pe cep ion and P o ec i e Beha io s du ing he Rise o he COVID-19 Ou b eak in I aly. F on Psychol (2021) 11:577331. doi:10.3389/ psyg.2020.577331 In J Public Heal h | Owned by SSPH+ | Published by F on ie s Janua y 2023 | Volume 67 | A icle 16046009 Cuad ado e al. COVID-19 Wo ies and Fea s Scale