Validation of the Pashto version of the 21-item Depression, Anxiety, and Stress Scale (DASS-21) among Afghans

Validation of the Pashto version of the 21-item Depression, Anxiety, and Stress Scale (DASS-21) among Afghans | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Validation of the Pashto version of the 21-item Depression, Anxiety, and Stress Scale (DASS-21) among Afghans Ahmad Neyazi, Karima Naseri, Mehrab Neyazi, Bilal Ahmad Rahimi, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7433674/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The 21-item depression, anxiety, and stress scale (DASS-21) is an important and useful self-administered screening instrument designed to measure depression, anxiety, and stress. Currently, there is no published study using the Pashto version of the DASS-21 scale. Hence, the main objective of this research was to study the psychometric properties of the Pashto version of the DASS-21 among Pashto-speaking adult Afghans living in Kandahar and Helmand provinces of Afghanistan. Methods This cross-sectional study was conducted between January and March 2024 among 619 adults using convenience sampling technique. The mean age of the study participants was 37.4 years, ranging from 18–100 years. Internal consistency was evaluated using Cronbach’s alpha. Test-retest reliability was assessed via the Intraclass Correlation Coefficient (ICC). Inter-rater agreement for the scale's test-retest reliability was examined using Cohen's kappa. Convergent validity was assessed through Pearson correlation analyses, comparing DASS-21 subscales (depression, anxiety, and stress) with the GHQ-28 (depression and anxiety subscales) and CES-D 20 (total and subscale scores). Results The Cronbach’s alpha for the 21 items was 0.942, which indicates excellent internal consistency. The total score revealed a commendable ICC of 0.902, reflecting a consistently reliable measure encompassing all subscales. The F-test was statistically significant across all dimensions, which further supported the scale's reliability, highlighting the measurement instrument's stability over the test-retest intervals. There were statistically significant positive correlations between the DASS-21 Depression subscale and both the CES-D-20 (r = 0.702) and the GHQ-28 Depression (r = 0.755). The DASS-21 Anxiety subscale showed strong positive correlations with the CES-D-20 (r = 0.622) and the GHQ-28 Anxiety (r = .659). The DASS-21 Stress subscale also exhibited comparable positive associations with the CES-D-20 (r = 0.700) and the GHQ-28 Anxiety (r = 0.663). Also, the DASS-21 Depression subscale demonstrated a strong positive correlation with both the DASS-21 Anxiety (r = 0.780) and the DASS-21 Stress (r = 0.806) subscales. Meanwhile, all subscales, along with the overall DASS-21, exhibited favorable fit indices, thereby supporting the proposed factor structure. Conclusion The Pashto version of DASS-21 is proven to be a reliable and valid instrument to assess the magnitude of depression, anxiety, and stress among the Pashto-speaking Afghan adult population in Kandahar and Helmand provinces. The Pashto version of the DASS-21 will allow Afghan clinicians and researchers to screen common mental health disorders among the Pashto-speaking Afghan population. DASS-21 Depression Anxiety Stress Pashto Afghanistan validation Figures Figure 1 Introduction Depression or depressive disorder is not an uncommon mental disorder. It involves a depressed mood or loss of pleasure or interest in activities for long periods of time. Globally, nearly 280 million people are suffering from depression, which is 50% more common among women than men. Approximately 3.8% of the global population have depression, with 5% of adults (4% men and 6% women) and 5.7% of people aged > 60 years (WHO, 2023a ). Alongside depression, anxiety is another mental disorder and excessive experience of fear and worry that is mostly accompanied by physical tension and other behavioral and cognitive symptoms. Anxiety causes interference with daily activities and can negatively affect the family, social, and academic/working life of a person. Globally, approximately 4% of people are suffering from anxiety. In 2019, nearly 301 million of the global population had anxiety, which makes it the most common mental disorder (WHO, 2023b). The Depression, Anxiety, and Stress Scale (DASS) by Professor Lovibond is an important and useful self-administered screening instrument or questionnaire that is designed to measure depression, anxiety, and stress. The DASS-depression focuses on low mood, motivation, and self-esteem; DASS-anxiety focuses on physiological arousal, perceived panic, and fear; while DASS-stress on tension and irritability. The original version of the questionnaire has 42 items, which has been extensively used in various populations to assess different negative mental health conditions (Lovibond & Lovibond, 1995 ). Later, the original author (Professor Lovibond) decided to introduce the shorter version (21-item depression, anxiety, and stress scale [DASS-21]). DASS-21 consists of 21 items, with seven items for each domain of depression, anxiety, and stress. Completion of the DASS-42 questionnaire takes approximately 10–20 minutes, while DASS-21 takes nearly 5–10 minutes (Parkitny & McAuley, 2010 ). Two studies in Herat, Afghanistan, utilized the Dari version of the DASS-42. The first, involving 1,310 adults, demonstrated high internal consistency (Cronbach’s alpha: 0.888, 0.866, 0.833 for depression, anxiety, and stress) and confirmed the tool’s reliability and validity for screening mental health disorders among Dari speakers (Shayan, Niazi, et al., 2021 ). The second study assessed 100 COVID-19 patients and found that depression, anxiety, and stress levels were elevated during infection but decreased after recovery, highlighting the negative psychological impact of COVID-19 (Shayan, Azizi, et al., 2021 ). A cross-sectional study was conducted in Kabul City, Afghanistan, to investigate the association between food insecurity and common mental health problems among 421 women of reproductive age. For the assessment of major mental health problems, they used the Dari version of the DASS-21 questionnaire. The prevalence of depression, anxiety, and stress among food-insecure participants was 89.4%, 90.8%, and 85.7%, respectively. These high rates likely reflect the compounded psychological burden faced by women of reproductive age in Kabul, who are disproportionately affected by food insecurity, socio-economic hardship, and limited access to healthcare. Food insecurity was significantly associated with depression (odds ratio [OR] 4.9), anxiety (OR 4.7), and stress (OR 3.8) (Zahidi et al., 2022 ). Despite the high prevalence of depression, anxiety, and stress reported among Afghan populations, there remains a lack of standardized, culturally validated screening instruments for Pashto speakers, who constitute a large proportion of Afghanistan’s population. Accurate measurement of these conditions is critical for early identification, timely intervention, and development of targeted mental health programs. The DASS-21 is a brief, widely used, and psychometrically robust tool that allows simultaneous assessment of depression, anxiety, and stress, making it particularly valuable in low-resource settings. Validating its Pashto version ensures that clinicians and researchers can reliably assess mental health among Pashto-speaking populations, thereby supporting evidence-based mental health policy and practice in Afghanistan. Materials and Methods This study employed a convenience sample of 619 adults from Kandahar and Helmand provinces, Afghanistan. Data collection was conducted between January and March 2024 by data collectors. Participants completed a self-administered survey comprising sociodemographic information and the DASS-21. Data were collected using paper-based (hard copy) questionnaires, which participants completed independently across the provinces. Trained data collectors supervised the process and provided assistance when clarification was needed. Eligibility criteria included: (i) permanent residency in Afghanistan, (ii) age of 18 years or older, (iii) proficiency in understanding and using the Pashto language, and (iv) the ability to provide written informed consent. Exclusion criteria included: (i) individuals with severe cognitive impairment or active psychosis that would prevent comprehension or completion of the questionnaire, (ii) those who were physically too ill to participate at the time of data collection, and (iii) individuals unwilling or unable to provide informed consent (written). Measures Section I Demographic questions were incorporated to collect essential participant information, covering variables such as age, gender, marital status, residency, economic status, and exposure to traumatic events within the preceding month (information on exposure to traumatic events within the preceding month was included because such events are known to significantly increase the risk of depression, anxiety, and stress, especially in conflict-affected populations such as Afghanistan). Section II In this study, the Pashto version of the DASS-21 was utilized. The scale consists of 21 items divided into three subscales—Depression (e.g., ‘I felt that I had nothing to look forward to’), Anxiety (e.g., ‘I felt I was close to panic’), and Stress (e.g., ‘I found it hard to wind down’)—each rated on a four-point Likert scale ranging from 0 (‘never’) to 3 (‘most or all of the time’). Scores are calculated separately for each subscale, with subscale scores ranging from 0 to 21 (seven items per subscale) and a total score range of 0 to 63. Subscale scores were summed and then multiplied by two to align with the severity cut-off scores established for the original 42-item DASS, thereby allowing comparability across studies. Higher cumulative scores reflect greater severity of depression, anxiety, or stress. The psychometric properties of the scale are detailed in the ‘Results’ section. Cronbach’s alpha was found 0.942. Section III : The General Health Questionnaire-28 (GHQ-28) (Sterling, 2011 ), including its Pashto version (Malakouti et al., 2007 ), evaluates psychological well-being across four dimensions: somatic symptoms, anxiety and insomnia, social dysfunction, and severe depression. This scale was utilized in the current study to assess convergent validity with the Pashto DASS-21. The questionnaire comprises 28 items (e.g., “Felt that life is entirely hopeless”), each rated on a four-point scale from 0 (“better than usual”) to 3 (“much worse than usual”). Subscale scores range from 0 to 21 (with seven items per subscale), and the total score spans from 0 to 84. Higher cumulative scores reflect increased levels of somatic symptoms, anxiety and insomnia, social dysfunction, and severe depression. Cronbach’s alpha was found 0.960. Section IV The Pashtu version of the Center for Epidemiological Studies Depression Scale (CES-D-20) (Radloff, 1977 ), including its Dari version (Neyazi et al., 2022 ), assesses the presence and severity of depressive symptoms and was utilized to examine the convergent validity of the Pashto DASS-21. This 20-item scale (e.g., “I did not feel like eating; my appetite was poor”) employs a four-point response format ranging from 0 (“rarely or none of the time”) to 3 (“most or all of the time”). Total scores range from 0 to 60, with higher scores indicating increased depressive symptomatology. Cronbach’s alpha was found 0.838. Translation process Previous studies utilizing the DASS-21 in Afghanistan have not detailed their translation process or published the Pashto version employed. Consequently, a rigorous and systematic translation of the DASS-21 from English to Pashto was undertaken, adhering to the Standards for Educational and Psychological Testing by the American Educational Research Association (AERA), American Psychological Association (APA), and National Council on Measurement in Education (NCME) (American Psychological Association, 2009). Experienced translators, who were native Pashto speakers, were selected to independently translate the DASS-21 items and instructions, ensuring clarity and cultural relevance while documenting translation choices and challenges. These initial translations were then thoroughly reviewed by a panel of four bilingual experts, including psychologists and linguists, to resolve discrepancies and ensure that the intended meanings were preserved. Subsequently, a separate bilingual translator conducted a back-translation of the Pashto version into English to identify and address any mistranslations, with the expert panel meticulously evaluating and correcting these issues. Finally, cognitive interviews with Pashto-speaking participants were conducted to evaluate the comprehensibility, clarity, and cultural appropriateness of the translated items, with revisions made as needed. Data analysis Internal consistency was evaluated using Cronbach’s alpha, with values above 0.65 deemed satisfactory. Test-retest reliability was assessed via the Intraclass Correlation Coefficient (ICC), with a threshold of 0.65 or higher considered acceptable. Results are presented with ICC values, corresponding 95% confidence intervals (CIs), F-test statistics, and p-values for both the total scale and subscales. Inter-rater agreement for the scale's test-retest reliability was examined using Cohen's kappa, involving 119 participants and including ICC values and p-values for the total and subscales. Convergent validity was assessed through Pearson correlation analyses, comparing DASS-21 subscales (depression, anxiety, and stress) with the GHQ-28 (depression and anxiety subscales) and CES-D 20 (total and subscale scores). The correlation coefficients and p-values indicate the degree of association between these psychological measures. The dimensionality of the DASS-21 and its subscales was examined using confirmatory factor analysis (CFA). Several fit indices were evaluated, including the Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), Adjusted Goodness-of-Fit Index (AGFI), Root Mean Square Error of Approximation (RMSEA), Normed Fit Index (NFI), Goodness-of-Fit Index (GFI), Standardized Root Mean Residual (SRMR), along with the chi-square test statistic (χ2) and degrees of freedom (df). This analysis followed established criteria: CMIN/df < 5; SRMR < 0.05; RMSEA 0.90; AGFI > 0.90; CFI > 0.95; and TLI > 0.95. All statistical analyses were performed using IBM SPSS Statistics, version 26, for Windows, with CFA conducted using AMOS version 26. Results Characteristics The current study comprised 619 participants, whose ages ranged from 18 to 100 years, with a mean ± SD age of 37.4 ± 13.1 years. A substantial majority of the participants were female (55.4%). Most participants reported being married (85.6%), and over two-thirds resided in urban areas (70.4%). Additionally, more than two-thirds (69.8%) of the participants indicated a low-income economic status. Furthermore, more than half (54.1%) of the participants reported having experienced a traumatic event within the past month. [ Table 1 ] Table 1 General characteristics of the study participants. Characteristic Result, n (%) ( N = 619) Age (mean ± SD) 37.4 ± 13.1 Age group 18–40 years 432 (69.8) > 40 years 187 (30.2) Gender Male 276 (44.6) Female 343 (55.4) Marital status Single 89 (14.4) Married 530 (85.6) Residency Urban 436 (70.4) Rural 183 (29.6) Economic status High income 50 (8.1) Middle income 137 (22.1) Low income 432 (69.8) Traumatic event Yes 284 (45.9) No 335 (54.1) SD, standard deviation; n, number; N, number. Table 2 presents the frequency of responses for each item, accompanied by Classical Test Theory (CTT) statistics. Participants utilized all four response categories. Nearly one-fifth of the participants (17.8%) reported no instances of "experiencing breathing difficulty" in the past week, while approximately 22.1% indicated no occurrences of feeling a "meaningless life" during the same period. Notably, Item 19, which pertains to the anxiety sub-scale ("I was aware of the action of my heart in the absence of physical exertion"), received the lowest endorsement in the "most or all of the time" category, with only 9.5% of respondents selecting this option. The internal consistency of the DASS-21 subscales was satisfactory, with Cronbach’s alpha coefficients of 0.794 for Anxiety, 0.870 for Depression, and 0.866 for Stress. Overall, the Cronbach’s alpha for the 21 items was 0.942, indicating excellent internal consistency. [ Table 2 ] Table 2 Abbreviated item content, response category percentages, and classical test theory statistics of DASS-21 scale items in the study participants (N = 619). No. Item Description Never (0) Sometimes (1) A lot of times (2) Most or all of time (3) Corrected Item – total correlation Cronbach’s alpha if the item is dropped Anxiety subscale % 2 I was aware of dryness of my mouth. 11.8 35.9 37.2 15.2 0.531 0.941 4 I experienced breathing difficulty. 17.8 35.1 34.2 12.9 0.643 0.939 7 I experienced trembling (e.g., in the hands). 11.5 35.4 36.3 16.8 0.545 0.941 9 I was worried about situations in which I might panic and make a fool of myself. 31.8 30.0 32.0 6.1 0.425 0.942 15 I felt I was close to panic. 19.5 31.0 36.5 12.9 0.690 0.938 19 I was aware of the action of my heart in the absence of physical exertion. 22.9 35.9 31.7 9.5 0.509 0.941 20 I feel scared without any good reason. 21.0 34.2 34.7 10.0 0.608 0.940 Depression subscale 3 I couldn’t seem to experience any positive feeling at all. 15.5 32.6 40.2 11.6 0.638 0.939 5 I find it difficult to work up the initiative to do things. 18.3 36.5 34.1 11.1 0.662 0.939 10 I felt that I had nothing to look forward to. 19.1 32.8 34.7 13.4 0.713 0.938 13 I felt down-hearted and blue. 17.6 27.3 36.3 18.7 0.720 0.938 16 I was unable to become enthusiastic about anything. 17.9 30.9 41.4 9.9 0.706 0.938 17 I felt I wasn’t worth much as a person. 21.2 28.9 37.8 12.1 0.717 0.938 21 I feel that life is meaningless. 22.1 28.3 34.6 15.0 0.674 0.939 Stress subscale 1 I find it hard to wind down. 13.7 43.0 32.8 10.5 0.652 0.939 6 I tend to over-react to situations. 17.6 36.8 36.5 9.0 0.588 0.940 8 I feel that I was using a lot of nervous energy. 14.4 33.9 36.7 15.0 0.623 0.939 11 I find myself getting agitated. 13.7 29.1 38.6 18.6 0.700 0.938 12 I find it is difficult to relax. 15.2 29.6 40.5 14.7 0.741 0.937 14 I was intolerant of anything that kept me from getting on with what I was doing. 15.5 30.2 38.1 16.2 0.636 0.939 18 I feel that I was rather touchy. 14.1 26.8 38.0 21.2 0.704 0.938 The findings indicated a strong and consistent level of test-retest reliability across all dimensions assessed. Specifically, the Anxiety subscale exhibited an ICC of 0.907 (95% CI: 0.866–0.935), indicating a high degree of agreement between the two test administrations. Similarly, the Depression and Stress subscales demonstrated substantial ICC values of 0.821 (95% CI: 0.742–0.875) and 0.861 (95% CI: 0.800–0.903), respectively, confirming the reliability of these constructs over time. The overall Total score showed a commendable ICC of 0.902 (95% CI: 0.859–0.931), reflecting a consistently reliable measure encompassing all subscales. Furthermore, the statistical significance of the F-test results ( p -value < 0.001) across all dimensions further supported the reliability of the scale, highlighting the stability of the measurement instrument over the test-retest intervals. [ Table 3 ] Table 3 Examining the interclass correlation coefficient between two rounds of the scale (n = 119). Scale/Subscale ICC (95% CI) F Test p -value Anxiety 0.907 (0.866–0.935) 10.71 < 0.001 Depression 0.821 (0.742–0.875) 5.58 < 0.001 Stress 0.861 (0.800–0.903) 7.17 < 0.001 Total 0.902 (0.859–0.931) 10.16 < 0.001 ICC, interclass correlation coefficient; CI, confidence interval. The results revealed substantial and statistically significant positive correlations between the DASS-21 Depression subscale and both the CES-D-20 (r = 0.702, p -value < 0.001) and the GHQ-28 Depression (r = 0.755, p -value < 0.001). Likewise, the DASS-21 Anxiety subscale showed strong positive correlations with the CES-D-20 (r = 0.622, p -value < .001) and the GHQ-28 Anxiety (r = 0.659, p -value < 0.001). The DASS-21 Stress subscale also exhibited comparable positive associations with the CES-D-20 (r = 0.700, p -value < .001) and the GHQ-28 Anxiety (r = 0.663, p -value < 0.001). Additionally, the DASS-21 Depression subscale demonstrated a strong positive correlation with both the DASS-21 Anxiety (r = 0.780, p -value < 0.001) and the DASS-21 Stress (r = 0.806, p -value < 0.001) subscales. [ Table 4 ] Table 4 Pearson Correlation between DASS-21-Depression, DASS-21-Anxiety, DASS-21-Stress, CES-D-20, GHQ-28-Somatic-symptoms, GHQ-28-Anxiety, GHQ-28-Social-dysfunction, and GHQ-28-Depression. Variables 1 2 3 4 5 6 7 8 1. DASS-21-Depression - - - - - - - - 2. DASS-21-Anxiety 0.780* < 0.001 - - - - - - - 3. DASS-21-Stress 0.806* < 0.001 0.746* < 0.001 - - - - - - 4. CES-20-Depression 0.702* < 0.001 0.622* < 0.001 0.700* < 0.001 - - - - - 5. GHQ-28-Somatic-symptoms 0.734* < 0.001 0.700* < 0.001 0.693* < 0.001 0.598* < 0.001 - - - - 6. GHQ-28-Anxiety 0.717* < 0.001 0.659* < 0.001 0.663* < 0.001 0.565* < 0.001 00.813* < 0.001 - - - 7. GHQ-28-Social-dysfunction 0.652* < 0.001 0.565* < 0.001 0.604* < 0.001 0.498* < 0.001 0.696* < 0.001 0.685* < 0.001 - - 8. GHQ-28-Depression 0.755* < 0.001 0.644* < 0.001 0.678* < 0.001 0.586* < 0.001 0.773* < 0.001 0.759* < 0.001 0.713* < 0.001 - *Correlation is significant at 0.01 level The RMSEA values for the depression, anxiety, and stress subscales were 0.071, 0.126, and 0.091, respectively indicating poor fit. Additional fit indices, including AGFI, GFI, and SRMR, were also computed, as shown in [ Table 5 ] . Notably, all subscales, along with the overall DASS-21, exhibited favorable fit indices, thereby supporting the proposed factor structure, as illustrated in [ Figure 1 ] . Table 5 Examining the dimensionality of the DASS-21 scale and its sub-scales using confirmatory factor analysis. Scale/Subscale CFI TLI AGFI RMSEA NFI GFI SRMR χ 2 (df) p -value Anxiety 0.874 0.811 0.852 0.126 0.864 0.926 0.053 152.130 (14) < 0.001 Depression 0.976 0.965 0.974 0.071 0.969 0.973 0.026 57.406 (14) < 0.001 Stress 0.960 0.939 0.916 0.091 0.952 0.958 0.033 85.033 (14) < 0.001 Overall DASS-21 0.897 0.884 0.829 0.077 0.874 0.863 0.041 868.426 (186) < 0.001 AFGI, Adjusted Goodness-of-Fit Index; CFI, Comparative Fit Index; df, degrees of freedom; GFI, Goodness-of-Fit Index; NFI, Normed Fit Index; RMSEA, Root Mean Square Error of Approximation; SRMR, Standardized Root Mean Residual; TLI, Tucker-Lewis Index; χ 2 , chi-square. Discussion This methodological study evaluated the psychometric properties of the Pashto version of the DASS-21 among 619 adult participants from Kandahar and Helmand provinces in southwest Afghanistan. The findings provide robust evidence supporting the reliability and validity of the instrument for use in Pashto-speaking populations. The overall internal consistency was excellent, with a Cronbach’s alpha of 0.942 for the full scale, well above the commonly accepted threshold of 0.70, suggesting that the items measure a coherent construct of psychological distress. The subscale-specific Cronbach’s alpha coefficients were also strong, indicating good reliability for each of the three domains—depression, anxiety, and stress. These results are in line with previous studies validating the DASS-21 in other cultural settings, confirming that the scale performs consistently across diverse populations. The test-retest reliability results in this study further reinforce the stability of the instrument over time. The intraclass correlation coefficients (ICCs) for the three subscales and the total score were all above 0.80, demonstrating a high level of reproducibility. This is a critical psychometric property because it ensures that repeated administrations of the instrument yield consistent results, making it a reliable tool for both clinical follow-up and research purposes. Such high temporal stability is consistent with findings from other validation studies, including the Persian version of the DASS-21 validated among Iranian nurses, which also reported acceptable test-retest reliability (p-value < 0.01) for the total scale and its three dimensions (Kakemam et al., 2022 ). The confirmatory factor analysis (CFA) results add an important dimension to the psychometric evaluation of the Pashto DASS-21. While the depression and stress subscales demonstrated satisfactory model fit, the anxiety subscale showed weaker fit indices, including an RMSEA slightly above the recommended cut-off. This finding is not unique to our study; it has been observed in other validation studies that the anxiety items sometimes exhibit weaker factorial validity and cross-loadings with stress items. For instance, a community-based study in India among young adults found that both a three-factor and a one-factor model provided a good fit for the data, with very strong correlations between the subscales (r ≥ 0.80), suggesting that the DASS-21 may be capturing general psychological distress rather than fully independent constructs (Sharma et al., 2020 ). Similarly, the large-scale Malaysian web-based validation study, which included 367,860 participants, demonstrated that stress items loaded onto both depression and anxiety domains, resulting in a two-factor solution (Musa & Mohammad Aidid, 2020 ). The parallels between our findings and the Malaysian results suggest that a two-factor or even unidimensional structure may better represent the underlying constructs of the DASS-21 in certain cultural or high-stress contexts. This is particularly relevant in Afghanistan, where the population has been exposed to prolonged conflict and trauma, potentially blurring the boundaries between symptoms of anxiety, stress, and depression. Clinicians and researchers using the Pashto DASS-21 should therefore be mindful of the strong intercorrelations between subscales and consider using total scores or combined subscale scores when appropriate. The convergent validity findings of the current study further support the use of the Pashto DASS-21 as a measure of psychological distress. The significant positive correlations between DASS-21 subscales and both the CES-D-20 and GHQ-28 provide strong evidence that the instrument accurately captures symptoms of depression, anxiety, and stress in this population. These results are consistent with other studies that have reported similar associations between DASS-21 subscales and other validated mental health instruments. The Nepali version of the DASS-21, for example, showed significant negative correlations with quality-of-life scores, suggesting that higher psychological distress measured by DASS-21 corresponds with lower well-being (Thapa et al., 2022 ). Together, these results highlight the cross-cultural robustness of the DASS-21 and its potential utility for mental health screening, epidemiological surveys, and outcome evaluations in Afghanistan. Importantly, the results of this study have practical implications. Afghanistan has a significant treatment gap for mental health disorders, with limited availability of trained mental health professionals and diagnostic tools. The Pashto DASS-21 offers a brief, easy-to-administer, and psychometrically sound screening instrument that can be implemented in community surveys, primary healthcare settings, and humanitarian programs to identify individuals at risk and guide resource allocation. Moreover, its validation helps standardize mental health research in Afghanistan, allowing for comparability of findings across studies and over time. While the results of this study are promising, several limitations should be acknowledged. First, the study utilized a non-clinical, community-based sample, which may limit the generalizability of the findings to clinical populations with diagnosed psychiatric disorders. Psychometric performance, including factor structure and severity cut-off scores, may differ in clinical settings, as shown in previous validation studies that reported variations in factor loadings between patient and non-patient samples (Kakemam et al., 2022 ). Future research should replicate this validation among clinical populations to ensure applicability in diagnostic contexts. Second, the educational background and literacy levels of participants were not collected in this study. Literacy has been shown to influence the comprehension of self-administered questionnaires and response patterns, potentially affecting the reliability of self-reported mental health data (Thapa et al., 2022 ). It is possible that individuals with lower literacy may have misinterpreted certain items, which could bias the results. Future studies should stratify analyses by education level and consider interviewer-administered approaches for low-literacy participants. Third, this study focused exclusively on adults aged 18 years and above, excluding adolescents and younger populations who represent a vulnerable group with high exposure to conflict-related stressors. Numerous studies have highlighted the elevated prevalence of depression, anxiety, and post-traumatic stress disorder among adolescents living in war-affected settings, underscoring the need for validated tools tailored to this age group. Validating the DASS-21 among adolescents would allow for early detection and intervention efforts that could mitigate the long-term psychological impact of conflict. Finally, the study employed a convenience sampling method, which, although practical and commonly used in conflict-affected regions, introduces the possibility of selection bias and may limit the representativeness of the sample. Participants who consented to take part may differ systematically from those who did not, potentially leading to an over- or under-estimation of psychological distress in the population. Future studies should consider probability-based sampling approaches where feasible to enhance the external validity and generalizability of findings. Conclusion and recommendation The findings of this study demonstrate that the Pashto version of the DASS-21 is a reliable and valid instrument for assessing depression, anxiety, and stress among adult Pashto-speaking populations in Kandahar and Helmand provinces. The scale exhibited excellent internal consistency, strong test-retest reliability, and good convergent validity with established mental health measures. Although the confirmatory factor analysis revealed a weaker fit for the anxiety subscale, the overall results support the use of the instrument as a robust screening tool. The validation of this instrument carries significant clinical and public health implications. The Pashto DASS-21 provides clinicians, psychologists, and community health workers with a brief, easy-to-administer tool that facilitates early identification of psychological distress, enabling timely referral and intervention in both community and primary care settings. Its integration into health programs and humanitarian initiatives could help address the large mental health treatment gap in Afghanistan by guiding resource allocation and service planning. Moreover, the availability of a standardized, psychometrically sound measure supports mental health research, monitoring, and evaluation efforts, contributing to the development of evidence-based mental health policies in the country. Future studies should replicate these findings in clinical populations, include participants from other Pashto-speaking provinces, and assess the scale’s applicability among adolescents to broaden its utility and maximize its role in shaping mental health strategies nationwide. Declarations Ethical approval and consent to participate Ethical approval for this study was obtained from the Afghanistan Center for Epidemiological Studies - Ethical Committee (Reference No. #23.1.074). Participants were provided with a comprehensive explanation of the study's objectives during the initial interaction. Written informed consent was obtained before participation, and individuals were assured of their right to withdraw from the study at any stage. All procedures were conducted in strict accordance with relevant ethical principles and regulatory guidelines. Consent for publication Not applicable Conflict of interest The authors assert that there are no conflicts of interest to disclose. Competing interest The authors declare that there are no competing interests to disclose. Funding This research received no external funding. Author Contribution - AN designed the study.- AN, SS, AGY, NR, and MN contributed to the data collection of this study.- AN analyzed the data.- AN, BAR, KN, SS, AGY, MN, PA, and NR prepared the draft of the manuscript.- AN critically reviewed, rewrote, edited, and finalized the manuscript.- All authors reviewed the manuscript. Data Availability The datasets utilized and/or analyzed in the course of the present study are accessible from the corresponding author upon reasonable inquiry. References The Standards for Educational and Psychological Testing. https://wwwapaorg [Internet]. 2009 [cited 2025 Feb 19]; Available from: https://www.apa.org/science/programs/testing/standards Kakemam, E., Navvabi, E., Albelbeisi, A. H., Saeedikia, F., Rouhi, A., & Majidi, S. (2022). Psychometric properties of the Persian version of Depression Anxiety Stress Scale-21 Items (DASS-21) in a sample of health professionals: A cross-sectional study. BMC Health Services Research , 22 (1), 111. https://doi.org/10.1186/s12913-022-07514-4 Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour Research and Therapy , 33 (3), 335–343. https://doi.org/10.1016/0005-7967(94)00075-U Malakouti, S. K., Fatollahi, P., Mirabzadeh, A., & Zandi, T. (2007). Reliability, validity and factor structure of the GHQ-28 used among elderly Iranians. International Psychogeriatrics , 19 (4), 623–634. https://doi.org/10.1017/S1041610206004522 Musa, R., & Mohammad Aidid, E. (2020). Psychometric Properties of the Depression Anxiety Stress Scale 21-item (DASS-21) Malay Version among a Big Sample Population of Non-Malays in Malaysia. Malaysian Journal of Psychiatry , 29 (1), 34. Neyazi, A., Tosun, N., Hosaini, F., & Saokaew, S. (2022). Validity and reliability of the Dari version of the CES-D scale among the general population of Herat, Afghanistan: A methodological study. Razi International Medical Journal , 2 (1), Article 1. https://doi.org/10.56101/rimj.v2i1.35 Parkitny, L., & McAuley, J. (2010). The Depression Anxiety Stress Scale (DASS). Journal of Physiotherapy , 56 (3), 204. https://doi.org/10.1016/S1836-9553(10)70030-8 Radloff, L. S. (1977). The CES-D Scale: A Self-Report Depression Scale for Research in the General Population. Applied Psychological Measurement , 1 (3), 385–401. https://doi.org/10.1177/014662167700100306 Sharma, M. K., Hallford, D. J., & Anand, N. (2020). Confirmatory factor analysis of the Depression, Anxiety, and Stress Scale among Indian adults. Indian Journal of Psychiatry , 62 (4), 379–383. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_313_19 Shayan, N. A., Azizi, A. T., Razaqi, N., Afzali, H., Neyazi, A., Waez, H., Noormohmmadi, M., & Bhattacharya, S. (2021). Phase wise assessment of COVID-19 related depression, anxiety, and stress level among patients in Herat city, Afghanistan—A descriptive study. Razi International Medical Journal , 1 (1), 1–9. https://doi.org/10.56101/rimj.v1i1.14 Shayan, N. A., Niazi, A.-R., Waseq, A. M., & Özcebe, H. (2021). Depression, Anxiety, and Stress Scales 42 (DASS-42) in Dari-Language: Validity and Reliability Study in Adults, Herat, Afghanistan. Bezmialem Science , 9 (3), 356–362. https://doi.org/10.14235/bas.galenos.2020.4250 Sterling, M. (2011). General Health Questionnaire—28 (GHQ-28). Journal of Physiotherapy , 57 (4), 259. https://doi.org/10.1016/S1836-9553(11)70060-1 Thapa, D. K., Visentin, D., Kornhaber, R., & Cleary, M. (2022). Psychometric properties of the Nepali language version of the Depression Anxiety Stress Scales (DASS-21). Nursing Open , 9 (6), 2608–2617. https://doi.org/10.1002/nop2.959 WHO. (2023a). Depressive disorder (depression) . World Health Organization. https://www.who.int/news-room/fact-sheets/detail/depression WHO. (2023b, September 27). Anxiety disorders . World Health Organization. https://www.who.int/news-room/fact-sheets/detail/anxiety-disorders Zahidi, F., Khalid, M., Surkan, P. J., & Azadbakht, L. (2022). Associations Between Food Insecurity and Common Mental Health Problems Among Reproductive-Aged Women in Kabul-Afghanistan. Frontiers in Nutrition , 8 , 794607. https://doi.org/10.3389/fnut.2021.794607 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7433674","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":573485320,"identity":"6024e985-73c8-4ae3-969c-baf40c406185","order_by":0,"name":"Ahmad 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1","display":"","copyAsset":false,"role":"figure","size":83945,"visible":true,"origin":"","legend":"\u003cp\u003eConfirmatory analysis model with factor loadings and correlations for the three Pashto-DASS-21 subscales.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7433674/v1/c3171c2b0bc211481fed331a.png"},{"id":105371593,"identity":"f7364587-564d-47f4-be32-2649f551b396","added_by":"auto","created_at":"2026-03-25 09:28:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1108044,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7433674/v1/c37414b7-eef7-4394-96e5-b307fd52df2a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Validation of the Pashto version of the 21-item Depression, Anxiety, and Stress Scale (DASS-21) among Afghans","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDepression or depressive disorder is not an uncommon mental disorder. It involves a depressed mood or loss of pleasure or interest in activities for long periods of time. Globally, nearly 280\u0026nbsp;million people are suffering from depression, which is 50% more common among women than men. Approximately 3.8% of the global population have depression, with 5% of adults (4% men and 6% women) and 5.7% of people aged\u0026thinsp;\u0026gt;\u0026thinsp;60 years (WHO, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2023a\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlongside depression, anxiety is another mental disorder and excessive experience of fear and worry that is mostly accompanied by physical tension and other behavioral and cognitive symptoms. Anxiety causes interference with daily activities and can negatively affect the family, social, and academic/working life of a person. Globally, approximately 4% of people are suffering from anxiety. In 2019, nearly 301\u0026nbsp;million of the global population had anxiety, which makes it the most common mental disorder (WHO, 2023b).\u003c/p\u003e \u003cp\u003eThe Depression, Anxiety, and Stress Scale (DASS) by Professor Lovibond is an important and useful self-administered screening instrument or questionnaire that is designed to measure depression, anxiety, and stress.\u003c/p\u003e \u003cp\u003eThe DASS-depression focuses on low mood, motivation, and self-esteem; DASS-anxiety focuses on physiological arousal, perceived panic, and fear; while DASS-stress on tension and irritability. The original version of the questionnaire has 42 items, which has been extensively used in various populations to assess different negative mental health conditions (Lovibond \u0026amp; Lovibond, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e1995\u003c/span\u003e). Later, the original author (Professor Lovibond) decided to introduce the shorter version (21-item depression, anxiety, and stress scale [DASS-21]). DASS-21 consists of 21 items, with seven items for each domain of depression, anxiety, and stress. Completion of the DASS-42 questionnaire takes approximately 10\u0026ndash;20 minutes, while DASS-21 takes nearly 5\u0026ndash;10 minutes (Parkitny \u0026amp; McAuley, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTwo studies in Herat, Afghanistan, utilized the Dari version of the DASS-42. The first, involving 1,310 adults, demonstrated high internal consistency (Cronbach\u0026rsquo;s alpha: 0.888, 0.866, 0.833 for depression, anxiety, and stress) and confirmed the tool\u0026rsquo;s reliability and validity for screening mental health disorders among Dari speakers (Shayan, Niazi, et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The second study assessed 100 COVID-19 patients and found that depression, anxiety, and stress levels were elevated during infection but decreased after recovery, highlighting the negative psychological impact of COVID-19 (Shayan, Azizi, et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA cross-sectional study was conducted in Kabul City, Afghanistan, to investigate the association between food insecurity and common mental health problems among 421 women of reproductive age. For the assessment of major mental health problems, they used the Dari version of the DASS-21 questionnaire. The prevalence of depression, anxiety, and stress among food-insecure participants was 89.4%, 90.8%, and 85.7%, respectively. These high rates likely reflect the compounded psychological burden faced by women of reproductive age in Kabul, who are disproportionately affected by food insecurity, socio-economic hardship, and limited access to healthcare. Food insecurity was significantly associated with depression (odds ratio [OR] 4.9), anxiety (OR 4.7), and stress (OR 3.8) (Zahidi et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite the high prevalence of depression, anxiety, and stress reported among Afghan populations, there remains a lack of standardized, culturally validated screening instruments for Pashto speakers, who constitute a large proportion of Afghanistan\u0026rsquo;s population. Accurate measurement of these conditions is critical for early identification, timely intervention, and development of targeted mental health programs. The DASS-21 is a brief, widely used, and psychometrically robust tool that allows simultaneous assessment of depression, anxiety, and stress, making it particularly valuable in low-resource settings. Validating its Pashto version ensures that clinicians and researchers can reliably assess mental health among Pashto-speaking populations, thereby supporting evidence-based mental health policy and practice in Afghanistan.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis study employed a convenience sample of 619 adults from Kandahar and Helmand provinces, Afghanistan. Data collection was conducted between January and March 2024 by data collectors. Participants completed a self-administered survey comprising sociodemographic information and the DASS-21. Data were collected using paper-based (hard copy) questionnaires, which participants completed independently across the provinces. Trained data collectors supervised the process and provided assistance when clarification was needed. Eligibility criteria included: (i) permanent residency in Afghanistan, (ii) age of 18 years or older, (iii) proficiency in understanding and using the Pashto language, and (iv) the ability to provide written informed consent. Exclusion criteria included: (i) individuals with severe cognitive impairment or active psychosis that would prevent comprehension or completion of the questionnaire, (ii) those who were physically too ill to participate at the time of data collection, and (iii) individuals unwilling or unable to provide informed consent (written).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eMeasures\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eSection I\u003c/strong\u003e \u003cp\u003eDemographic questions were incorporated to collect essential participant information, covering variables such as age, gender, marital status, residency, economic status, and exposure to traumatic events within the preceding month (information on exposure to traumatic events within the preceding month was included because such events are known to significantly increase the risk of depression, anxiety, and stress, especially in conflict-affected populations such as Afghanistan).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSection II\u003c/strong\u003e \u003cp\u003eIn this study, the Pashto version of the DASS-21 was utilized. The scale consists of 21 items divided into three subscales\u0026mdash;Depression (e.g., \u0026lsquo;I felt that I had nothing to look forward to\u0026rsquo;), Anxiety (e.g., \u0026lsquo;I felt I was close to panic\u0026rsquo;), and Stress (e.g., \u0026lsquo;I found it hard to wind down\u0026rsquo;)\u0026mdash;each rated on a four-point Likert scale ranging from 0 (\u0026lsquo;never\u0026rsquo;) to 3 (\u0026lsquo;most or all of the time\u0026rsquo;). Scores are calculated separately for each subscale, with subscale scores ranging from 0 to 21 (seven items per subscale) and a total score range of 0 to 63. Subscale scores were summed and then multiplied by two to align with the severity cut-off scores established for the original 42-item DASS, thereby allowing comparability across studies. Higher cumulative scores reflect greater severity of depression, anxiety, or stress. The psychometric properties of the scale are detailed in the \u0026lsquo;Results\u0026rsquo; section. Cronbach\u0026rsquo;s alpha was found 0.942.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSection III\u003c/b\u003e: The General Health Questionnaire-28 (GHQ-28) (Sterling, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2011\u003c/span\u003e), including its Pashto version (Malakouti et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2007\u003c/span\u003e), evaluates psychological well-being across four dimensions: somatic symptoms, anxiety and insomnia, social dysfunction, and severe depression. This scale was utilized in the current study to assess convergent validity with the Pashto DASS-21. The questionnaire comprises 28 items (e.g., \u0026ldquo;Felt that life is entirely hopeless\u0026rdquo;), each rated on a four-point scale from 0 (\u0026ldquo;better than usual\u0026rdquo;) to 3 (\u0026ldquo;much worse than usual\u0026rdquo;). Subscale scores range from 0 to 21 (with seven items per subscale), and the total score spans from 0 to 84. Higher cumulative scores reflect increased levels of somatic symptoms, anxiety and insomnia, social dysfunction, and severe depression. Cronbach\u0026rsquo;s alpha was found 0.960.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSection IV\u003c/strong\u003e \u003cp\u003eThe Pashtu version of the Center for Epidemiological Studies Depression Scale (CES-D-20) (Radloff, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e1977\u003c/span\u003e), including its Dari version (Neyazi et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), assesses the presence and severity of depressive symptoms and was utilized to examine the convergent validity of the Pashto DASS-21. This 20-item scale (e.g., \u0026ldquo;I did not feel like eating; my appetite was poor\u0026rdquo;) employs a four-point response format ranging from 0 (\u0026ldquo;rarely or none of the time\u0026rdquo;) to 3 (\u0026ldquo;most or all of the time\u0026rdquo;). Total scores range from 0 to 60, with higher scores indicating increased depressive symptomatology. Cronbach\u0026rsquo;s alpha was found 0.838.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTranslation process\u003c/h3\u003e\n\u003cp\u003ePrevious studies utilizing the DASS-21 in Afghanistan have not detailed their translation process or published the Pashto version employed. Consequently, a rigorous and systematic translation of the DASS-21 from English to Pashto was undertaken, adhering to the Standards for Educational and Psychological Testing by the American Educational Research Association (AERA), American Psychological Association (APA), and National Council on Measurement in Education (NCME) (American Psychological Association, 2009). Experienced translators, who were native Pashto speakers, were selected to independently translate the DASS-21 items and instructions, ensuring clarity and cultural relevance while documenting translation choices and challenges. These initial translations were then thoroughly reviewed by a panel of four bilingual experts, including psychologists and linguists, to resolve discrepancies and ensure that the intended meanings were preserved. Subsequently, a separate bilingual translator conducted a back-translation of the Pashto version into English to identify and address any mistranslations, with the expert panel meticulously evaluating and correcting these issues. Finally, cognitive interviews with Pashto-speaking participants were conducted to evaluate the comprehensibility, clarity, and cultural appropriateness of the translated items, with revisions made as needed.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eInternal consistency was evaluated using Cronbach\u0026rsquo;s alpha, with values above 0.65 deemed satisfactory. Test-retest reliability was assessed via the Intraclass Correlation Coefficient (ICC), with a threshold of 0.65 or higher considered acceptable. Results are presented with ICC values, corresponding 95% confidence intervals (CIs), F-test statistics, and p-values for both the total scale and subscales. Inter-rater agreement for the scale's test-retest reliability was examined using Cohen's kappa, involving 119 participants and including ICC values and p-values for the total and subscales. Convergent validity was assessed through Pearson correlation analyses, comparing DASS-21 subscales (depression, anxiety, and stress) with the GHQ-28 (depression and anxiety subscales) and CES-D 20 (total and subscale scores). The correlation coefficients and p-values indicate the degree of association between these psychological measures. The dimensionality of the DASS-21 and its subscales was examined using confirmatory factor analysis (CFA). Several fit indices were evaluated, including the Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), Adjusted Goodness-of-Fit Index (AGFI), Root Mean Square Error of Approximation (RMSEA), Normed Fit Index (NFI), Goodness-of-Fit Index (GFI), Standardized Root Mean Residual (SRMR), along with the chi-square test statistic (χ2) and degrees of freedom (df). This analysis followed established criteria: CMIN/df\u0026thinsp;\u0026lt;\u0026thinsp;5; SRMR\u0026thinsp;\u0026lt;\u0026thinsp;0.05; RMSEA\u0026thinsp;\u0026lt;\u0026thinsp;0.08; GFI\u0026thinsp;\u0026gt;\u0026thinsp;0.90; AGFI\u0026thinsp;\u0026gt;\u0026thinsp;0.90; CFI\u0026thinsp;\u0026gt;\u0026thinsp;0.95; and TLI\u0026thinsp;\u0026gt;\u0026thinsp;0.95. All statistical analyses were performed using IBM SPSS Statistics, version 26, for Windows, with CFA conducted using AMOS version 26.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics\u003c/h2\u003e \u003cp\u003eThe current study comprised 619 participants, whose ages ranged from 18 to 100 years, with a mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD age of 37.4\u0026thinsp;\u0026plusmn;\u0026thinsp;13.1 years. A substantial majority of the participants were female (55.4%). Most participants reported being married (85.6%), and over two-thirds resided in urban areas (70.4%). Additionally, more than two-thirds (69.8%) of the participants indicated a low-income economic status. Furthermore, more than half (54.1%) of the participants reported having experienced a traumatic event within the past month. \u003cb\u003e[\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGeneral characteristics of the study participants.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eResult, n (%) (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;619)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.4\u0026thinsp;\u0026plusmn;\u0026thinsp;13.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u0026ndash;40 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e432 (69.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;40 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e187 (30.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e276 (44.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e343 (55.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89 (14.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e530 (85.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eResidency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e436 (70.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e183 (29.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eEconomic status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (8.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e137 (22.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e432 (69.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eTraumatic event\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e284 (45.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e335 (54.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSD, standard deviation; n, number; N, number.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the frequency of responses for each item, accompanied by Classical Test Theory (CTT) statistics. Participants utilized all four response categories. Nearly one-fifth of the participants (17.8%) reported no instances of \"experiencing breathing difficulty\" in the past week, while approximately 22.1% indicated no occurrences of feeling a \"meaningless life\" during the same period. Notably, Item 19, which pertains to the anxiety sub-scale (\"I was aware of the action of my heart in the absence of physical exertion\"), received the lowest endorsement in the \"most or all of the time\" category, with only 9.5% of respondents selecting this option. The internal consistency of the DASS-21 subscales was satisfactory, with Cronbach\u0026rsquo;s alpha coefficients of 0.794 for Anxiety, 0.870 for Depression, and 0.866 for Stress. Overall, the Cronbach\u0026rsquo;s alpha for the 21 items was 0.942, indicating excellent internal consistency. \u003cb\u003e[\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAbbreviated item content, response category percentages, and classical test theory statistics of DASS-21 scale items in the study participants (N\u0026thinsp;=\u0026thinsp;619).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eItem Description\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNever (0)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSometimes (1)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eA lot of times (2)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMost or all of time (3)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCorrected Item \u0026ndash; total correlation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCronbach\u0026rsquo;s alpha if the item is dropped\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnxiety subscale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI was aware of dryness of my mouth.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e37.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.531\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.941\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI experienced breathing difficulty.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.643\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.939\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI experienced trembling (e.g., in the hands).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e36.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e16.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.545\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.941\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI was worried about situations in which I might panic and make a fool of myself.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e32.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.425\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.942\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI felt I was close to panic.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e36.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.690\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.938\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI was aware of the action of my heart in the absence of physical exertion.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e31.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.509\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.941\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI feel scared without any good reason.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.608\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.940\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDepression subscale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI couldn\u0026rsquo;t seem to experience any positive feeling at all.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e40.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.638\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.939\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI find it difficult to work up the initiative to do things.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.662\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.939\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI felt that I had nothing to look forward to.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e13.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.713\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.938\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI felt down-hearted and blue.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e36.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e18.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.720\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.938\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI was unable to become enthusiastic about anything.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e41.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.706\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.938\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI felt I wasn\u0026rsquo;t worth much as a person.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e37.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.717\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.938\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI feel that life is meaningless.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.674\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.939\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStress subscale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI find it hard to wind down.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e32.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.652\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.939\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI tend to over-react to situations.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e36.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.588\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.940\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI feel that I was using a lot of nervous energy.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e36.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e15.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.623\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.939\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI find myself getting agitated.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e38.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e18.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.700\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.938\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI find it is difficult to relax.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e40.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.741\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.937\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI was intolerant of anything that kept me from getting on with what I was doing.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e38.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e16.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.636\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.939\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eI feel that I was rather touchy.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e38.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e21.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.704\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.938\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe findings indicated a strong and consistent level of test-retest reliability across all dimensions assessed. Specifically, the Anxiety subscale exhibited an ICC of 0.907 (95% CI: 0.866\u0026ndash;0.935), indicating a high degree of agreement between the two test administrations. Similarly, the Depression and Stress subscales demonstrated substantial ICC values of 0.821 (95% CI: 0.742\u0026ndash;0.875) and 0.861 (95% CI: 0.800\u0026ndash;0.903), respectively, confirming the reliability of these constructs over time. The overall Total score showed a commendable ICC of 0.902 (95% CI: 0.859\u0026ndash;0.931), reflecting a consistently reliable measure encompassing all subscales. Furthermore, the statistical significance of the F-test results (\u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001) across all dimensions further supported the reliability of the scale, highlighting the stability of the measurement instrument over the test-retest intervals. \u003cb\u003e[\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eExamining the interclass correlation coefficient between two rounds of the scale (n\u0026thinsp;=\u0026thinsp;119).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScale/Subscale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eICC (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF Test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.907 (0.866\u0026ndash;0.935)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.821 (0.742\u0026ndash;0.875)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.861 (0.800\u0026ndash;0.903)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.902 (0.859\u0026ndash;0.931)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eICC, interclass correlation coefficient; CI, confidence interval.\u003c/p\u003e \u003cp\u003eThe results revealed substantial and statistically significant positive correlations between the DASS-21 Depression subscale and both the CES-D-20 (r\u0026thinsp;=\u0026thinsp;0.702, \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and the GHQ-28 Depression (r\u0026thinsp;=\u0026thinsp;0.755, \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Likewise, the DASS-21 Anxiety subscale showed strong positive correlations with the CES-D-20 (r\u0026thinsp;=\u0026thinsp;0.622, \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;.001) and the GHQ-28 Anxiety (r\u0026thinsp;=\u0026thinsp;0.659, \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The DASS-21 Stress subscale also exhibited comparable positive associations with the CES-D-20 (r\u0026thinsp;=\u0026thinsp;0.700, \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;.001) and the GHQ-28 Anxiety (r\u0026thinsp;=\u0026thinsp;0.663, \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Additionally, the DASS-21 Depression subscale demonstrated a strong positive correlation with both the DASS-21 Anxiety (r\u0026thinsp;=\u0026thinsp;0.780, \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and the DASS-21 Stress (r\u0026thinsp;=\u0026thinsp;0.806, \u003cem\u003ep\u003c/em\u003e-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001) subscales. \u003cb\u003e[\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e]\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePearson Correlation between DASS-21-Depression, DASS-21-Anxiety, DASS-21-Stress, CES-D-20, GHQ-28-Somatic-symptoms, GHQ-28-Anxiety, GHQ-28-Social-dysfunction, and GHQ-28-Depression.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. DASS-21-Depression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. DASS-21-Anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.780*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. DASS-21-Stress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.806*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.746*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. CES-20-Depression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.702*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.622*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.700*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. GHQ-28-Somatic-symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.734*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.700*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.693*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.598*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. GHQ-28-Anxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.717*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.659*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.663*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.565*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e00.813*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. GHQ-28-Social-dysfunction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.652*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.565*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.604*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.498*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.696*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.685*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. GHQ-28-Depression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.755*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.644*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.678*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.586*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.773*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.759*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.713*\u003c/p\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e*Correlation is significant at 0.01 level\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe RMSEA values for the depression, anxiety, and stress subscales were 0.071, 0.126, and 0.091, respectively indicating poor fit. Additional fit indices, including AGFI, GFI, and SRMR, were also computed, as shown in \u003cb\u003e[\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003cb\u003e]\u003c/b\u003e. Notably, all subscales, along with the overall DASS-21, exhibited favorable fit indices, thereby supporting the proposed factor structure, as illustrated in \u003cb\u003e[\u003c/b\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e]\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eExamining the dimensionality of the DASS-21 scale and its sub-scales using confirmatory factor analysis.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScale/Subscale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCFI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTLI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAGFI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRMSEA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNFI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGFI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSRMR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e (df)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.874\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.811\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.852\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.864\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.926\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.053\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e152.130 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.976\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.965\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.974\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.071\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.969\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.973\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e57.406 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.960\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.939\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.916\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.091\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.952\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.958\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.033\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e85.033 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall DASS-21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.897\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.884\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.829\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.077\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.874\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.863\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.041\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e868.426 (186)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAFGI, Adjusted Goodness-of-Fit Index; CFI, Comparative Fit Index; df, degrees of freedom; GFI, Goodness-of-Fit Index; NFI, Normed Fit Index; RMSEA, Root Mean Square Error of Approximation; SRMR, Standardized Root Mean Residual; TLI, Tucker-Lewis Index; χ\u003csup\u003e2\u003c/sup\u003e, chi-square.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis methodological study evaluated the psychometric properties of the Pashto version of the DASS-21 among 619 adult participants from Kandahar and Helmand provinces in southwest Afghanistan. The findings provide robust evidence supporting the reliability and validity of the instrument for use in Pashto-speaking populations. The overall internal consistency was excellent, with a Cronbach\u0026rsquo;s alpha of 0.942 for the full scale, well above the commonly accepted threshold of 0.70, suggesting that the items measure a coherent construct of psychological distress. The subscale-specific Cronbach\u0026rsquo;s alpha coefficients were also strong, indicating good reliability for each of the three domains\u0026mdash;depression, anxiety, and stress. These results are in line with previous studies validating the DASS-21 in other cultural settings, confirming that the scale performs consistently across diverse populations.\u003c/p\u003e \u003cp\u003eThe test-retest reliability results in this study further reinforce the stability of the instrument over time. The intraclass correlation coefficients (ICCs) for the three subscales and the total score were all above 0.80, demonstrating a high level of reproducibility. This is a critical psychometric property because it ensures that repeated administrations of the instrument yield consistent results, making it a reliable tool for both clinical follow-up and research purposes. Such high temporal stability is consistent with findings from other validation studies, including the Persian version of the DASS-21 validated among Iranian nurses, which also reported acceptable test-retest reliability (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.01) for the total scale and its three dimensions (Kakemam et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe confirmatory factor analysis (CFA) results add an important dimension to the psychometric evaluation of the Pashto DASS-21. While the depression and stress subscales demonstrated satisfactory model fit, the anxiety subscale showed weaker fit indices, including an RMSEA slightly above the recommended cut-off. This finding is not unique to our study; it has been observed in other validation studies that the anxiety items sometimes exhibit weaker factorial validity and cross-loadings with stress items. For instance, a community-based study in India among young adults found that both a three-factor and a one-factor model provided a good fit for the data, with very strong correlations between the subscales (r\u0026thinsp;\u0026ge;\u0026thinsp;0.80), suggesting that the DASS-21 may be capturing general psychological distress rather than fully independent constructs (Sharma et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Similarly, the large-scale Malaysian web-based validation study, which included 367,860 participants, demonstrated that stress items loaded onto both depression and anxiety domains, resulting in a two-factor solution (Musa \u0026amp; Mohammad Aidid, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The parallels between our findings and the Malaysian results suggest that a two-factor or even unidimensional structure may better represent the underlying constructs of the DASS-21 in certain cultural or high-stress contexts. This is particularly relevant in Afghanistan, where the population has been exposed to prolonged conflict and trauma, potentially blurring the boundaries between symptoms of anxiety, stress, and depression. Clinicians and researchers using the Pashto DASS-21 should therefore be mindful of the strong intercorrelations between subscales and consider using total scores or combined subscale scores when appropriate.\u003c/p\u003e \u003cp\u003eThe convergent validity findings of the current study further support the use of the Pashto DASS-21 as a measure of psychological distress. The significant positive correlations between DASS-21 subscales and both the CES-D-20 and GHQ-28 provide strong evidence that the instrument accurately captures symptoms of depression, anxiety, and stress in this population. These results are consistent with other studies that have reported similar associations between DASS-21 subscales and other validated mental health instruments. The Nepali version of the DASS-21, for example, showed significant negative correlations with quality-of-life scores, suggesting that higher psychological distress measured by DASS-21 corresponds with lower well-being (Thapa et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Together, these results highlight the cross-cultural robustness of the DASS-21 and its potential utility for mental health screening, epidemiological surveys, and outcome evaluations in Afghanistan.\u003c/p\u003e \u003cp\u003eImportantly, the results of this study have practical implications. Afghanistan has a significant treatment gap for mental health disorders, with limited availability of trained mental health professionals and diagnostic tools. The Pashto DASS-21 offers a brief, easy-to-administer, and psychometrically sound screening instrument that can be implemented in community surveys, primary healthcare settings, and humanitarian programs to identify individuals at risk and guide resource allocation. Moreover, its validation helps standardize mental health research in Afghanistan, allowing for comparability of findings across studies and over time.\u003c/p\u003e \u003cp\u003eWhile the results of this study are promising, several limitations should be acknowledged. First, the study utilized a non-clinical, community-based sample, which may limit the generalizability of the findings to clinical populations with diagnosed psychiatric disorders. Psychometric performance, including factor structure and severity cut-off scores, may differ in clinical settings, as shown in previous validation studies that reported variations in factor loadings between patient and non-patient samples (Kakemam et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Future research should replicate this validation among clinical populations to ensure applicability in diagnostic contexts. Second, the educational background and literacy levels of participants were not collected in this study. Literacy has been shown to influence the comprehension of self-administered questionnaires and response patterns, potentially affecting the reliability of self-reported mental health data (Thapa et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). It is possible that individuals with lower literacy may have misinterpreted certain items, which could bias the results. Future studies should stratify analyses by education level and consider interviewer-administered approaches for low-literacy participants. Third, this study focused exclusively on adults aged 18 years and above, excluding adolescents and younger populations who represent a vulnerable group with high exposure to conflict-related stressors. Numerous studies have highlighted the elevated prevalence of depression, anxiety, and post-traumatic stress disorder among adolescents living in war-affected settings, underscoring the need for validated tools tailored to this age group. Validating the DASS-21 among adolescents would allow for early detection and intervention efforts that could mitigate the long-term psychological impact of conflict. Finally, the study employed a convenience sampling method, which, although practical and commonly used in conflict-affected regions, introduces the possibility of selection bias and may limit the representativeness of the sample. Participants who consented to take part may differ systematically from those who did not, potentially leading to an over- or under-estimation of psychological distress in the population. Future studies should consider probability-based sampling approaches where feasible to enhance the external validity and generalizability of findings.\u003c/p\u003e"},{"header":"Conclusion and recommendation","content":"\u003cp\u003eThe findings of this study demonstrate that the Pashto version of the DASS-21 is a reliable and valid instrument for assessing depression, anxiety, and stress among adult Pashto-speaking populations in Kandahar and Helmand provinces. The scale exhibited excellent internal consistency, strong test-retest reliability, and good convergent validity with established mental health measures. Although the confirmatory factor analysis revealed a weaker fit for the anxiety subscale, the overall results support the use of the instrument as a robust screening tool. The validation of this instrument carries significant clinical and public health implications. The Pashto DASS-21 provides clinicians, psychologists, and community health workers with a brief, easy-to-administer tool that facilitates early identification of psychological distress, enabling timely referral and intervention in both community and primary care settings. Its integration into health programs and humanitarian initiatives could help address the large mental health treatment gap in Afghanistan by guiding resource allocation and service planning. Moreover, the availability of a standardized, psychometrically sound measure supports mental health research, monitoring, and evaluation efforts, contributing to the development of evidence-based mental health policies in the country. Future studies should replicate these findings in clinical populations, include participants from other Pashto-speaking provinces, and assess the scale\u0026rsquo;s applicability among adolescents to broaden its utility and maximize its role in shaping mental health strategies nationwide.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e \u003cp\u003eEthical approval for this study was obtained from the Afghanistan Center for Epidemiological Studies - Ethical Committee (Reference No. #23.1.074). Participants were provided with a comprehensive explanation of the study's objectives during the initial interaction. Written informed consent was obtained before participation, and individuals were assured of their right to withdraw from the study at any stage. All procedures were conducted in strict accordance with relevant ethical principles and regulatory guidelines.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConflict of interest\u003c/strong\u003e \u003cp\u003eThe authors assert that there are no conflicts of interest to disclose.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interest\u003c/strong\u003e \u003cp\u003eThe authors declare that there are no competing interests to disclose.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research received no external funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003e- AN designed the study.- AN, SS, AGY, NR, and MN contributed to the data collection of this study.- AN analyzed the data.- AN, BAR, KN, SS, AGY, MN, PA, and NR prepared the draft of the manuscript.- AN critically reviewed, rewrote, edited, and finalized the manuscript.- All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets utilized and/or analyzed in the course of the present study are accessible from the corresponding author upon reasonable inquiry.\u003c/p\u003e"},{"header":"References","content":"\u003cp\u003eThe Standards for Educational and Psychological Testing. https://wwwapaorg [Internet]. 2009 [cited 2025 Feb 19]; Available from: https://www.apa.org/science/programs/testing/standards\u003c/p\u003e\n\u003cp\u003eKakemam, E., Navvabi, E., Albelbeisi, A. H., Saeedikia, F., Rouhi, A., \u0026amp; Majidi, S. (2022). Psychometric properties of the Persian version of Depression Anxiety Stress Scale-21 Items (DASS-21) in a sample of health professionals: A cross-sectional study. \u003cem\u003eBMC Health Services Research\u003c/em\u003e, \u003cem\u003e22\u003c/em\u003e(1), 111. https://doi.org/10.1186/s12913-022-07514-4\u003c/p\u003e\n\u003cp\u003eLovibond, P. F., \u0026amp; Lovibond, S. H. (1995). The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. \u003cem\u003eBehaviour Research and Therapy\u003c/em\u003e, \u003cem\u003e33\u003c/em\u003e(3), 335\u0026ndash;343. https://doi.org/10.1016/0005-7967(94)00075-U\u003c/p\u003e\n\u003cp\u003eMalakouti, S. K., Fatollahi, P., Mirabzadeh, A., \u0026amp; Zandi, T. (2007). Reliability, validity and factor structure of the GHQ-28 used among elderly Iranians. \u003cem\u003eInternational Psychogeriatrics\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(4), 623\u0026ndash;634. https://doi.org/10.1017/S1041610206004522\u003c/p\u003e\n\u003cp\u003eMusa, R., \u0026amp; Mohammad Aidid, E. (2020). Psychometric Properties of the Depression Anxiety Stress Scale 21-item (DASS-21) Malay Version among a Big Sample Population of Non-Malays in Malaysia. \u003cem\u003eMalaysian Journal of Psychiatry\u003c/em\u003e, \u003cem\u003e29\u003c/em\u003e(1), 34.\u003c/p\u003e\n\u003cp\u003eNeyazi, A., Tosun, N., Hosaini, F., \u0026amp; Saokaew, S. (2022). Validity and reliability of the Dari version of the CES-D scale among the general population of Herat, Afghanistan: A methodological study. \u003cem\u003eRazi International Medical Journal\u003c/em\u003e, \u003cem\u003e2\u003c/em\u003e(1), Article 1. https://doi.org/10.56101/rimj.v2i1.35\u003c/p\u003e\n\u003cp\u003eParkitny, L., \u0026amp; McAuley, J. (2010). The Depression Anxiety Stress Scale (DASS). \u003cem\u003eJournal of Physiotherapy\u003c/em\u003e, \u003cem\u003e56\u003c/em\u003e(3), 204. https://doi.org/10.1016/S1836-9553(10)70030-8\u003c/p\u003e\n\u003cp\u003eRadloff, L. S. (1977). The CES-D Scale: A Self-Report Depression Scale for Research in the General Population. \u003cem\u003eApplied Psychological Measurement\u003c/em\u003e, \u003cem\u003e1\u003c/em\u003e(3), 385\u0026ndash;401. https://doi.org/10.1177/014662167700100306\u003c/p\u003e\n\u003cp\u003eSharma, M. K., Hallford, D. J., \u0026amp; Anand, N. (2020). Confirmatory factor analysis of the Depression, Anxiety, and Stress Scale among Indian adults. \u003cem\u003eIndian Journal of Psychiatry\u003c/em\u003e, \u003cem\u003e62\u003c/em\u003e(4), 379\u0026ndash;383. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_313_19\u003c/p\u003e\n\u003cp\u003eShayan, N. A., Azizi, A. T., Razaqi, N., Afzali, H., Neyazi, A., Waez, H., Noormohmmadi, M., \u0026amp; Bhattacharya, S. (2021). Phase wise assessment of COVID-19 related depression, anxiety, and stress level among patients in Herat city, Afghanistan\u0026mdash;A descriptive study. \u003cem\u003eRazi International Medical Journal\u003c/em\u003e, \u003cem\u003e1\u003c/em\u003e(1), 1\u0026ndash;9. https://doi.org/10.56101/rimj.v1i1.14\u003c/p\u003e\n\u003cp\u003eShayan, N. A., Niazi, A.-R., Waseq, A. M., \u0026amp; \u0026Ouml;zcebe, H. (2021). Depression, Anxiety, and Stress Scales 42 (DASS-42) in Dari-Language: Validity and Reliability Study in Adults, Herat, Afghanistan. \u003cem\u003eBezmialem Science\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e(3), 356\u0026ndash;362. https://doi.org/10.14235/bas.galenos.2020.4250\u003c/p\u003e\n\u003cp\u003eSterling, M. (2011). General Health Questionnaire\u0026mdash;28 (GHQ-28). \u003cem\u003eJournal of Physiotherapy\u003c/em\u003e, \u003cem\u003e57\u003c/em\u003e(4), 259. https://doi.org/10.1016/S1836-9553(11)70060-1\u003c/p\u003e\n\u003cp\u003eThapa, D. K., Visentin, D., Kornhaber, R., \u0026amp; Cleary, M. (2022). Psychometric properties of the Nepali language version of the Depression Anxiety Stress Scales (DASS-21). \u003cem\u003eNursing Open\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e(6), 2608\u0026ndash;2617. https://doi.org/10.1002/nop2.959\u003c/p\u003e\n\u003cp\u003eWHO. (2023a). \u003cem\u003eDepressive disorder (depression)\u003c/em\u003e. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/depression\u003c/p\u003e\n\u003cp\u003eWHO. (2023b, September 27). \u003cem\u003eAnxiety disorders\u003c/em\u003e. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/anxiety-disorders\u003c/p\u003e\n\u003cp\u003eZahidi, F., Khalid, M., Surkan, P. J., \u0026amp; Azadbakht, L. (2022). Associations Between Food Insecurity and Common Mental Health Problems Among Reproductive-Aged Women in Kabul-Afghanistan. \u003cem\u003eFrontiers in Nutrition\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e, 794607. https://doi.org/10.3389/fnut.2021.794607\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"DASS-21, Depression, Anxiety, Stress, Pashto, Afghanistan, validation","lastPublishedDoi":"10.21203/rs.3.rs-7433674/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7433674/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe 21-item depression, anxiety, and stress scale (DASS-21) is an important and useful self-administered screening instrument designed to measure depression, anxiety, and stress. Currently, there is no published study using the Pashto version of the DASS-21 scale. Hence, the main objective of this research was to study the psychometric properties of the Pashto version of the DASS-21 among Pashto-speaking adult Afghans living in Kandahar and Helmand provinces of Afghanistan.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis cross-sectional study was conducted between January and March 2024 among 619 adults using convenience sampling technique. The mean age of the study participants was 37.4 years, ranging from 18\u0026ndash;100 years. Internal consistency was evaluated using Cronbach\u0026rsquo;s alpha. Test-retest reliability was assessed via the Intraclass Correlation Coefficient (ICC). Inter-rater agreement for the scale's test-retest reliability was examined using Cohen's kappa. Convergent validity was assessed through Pearson correlation analyses, comparing DASS-21 subscales (depression, anxiety, and stress) with the GHQ-28 (depression and anxiety subscales) and CES-D 20 (total and subscale scores).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe Cronbach\u0026rsquo;s alpha for the 21 items was 0.942, which indicates excellent internal consistency. The total score revealed a commendable ICC of 0.902, reflecting a consistently reliable measure encompassing all subscales. The F-test was statistically significant across all dimensions, which further supported the scale's reliability, highlighting the measurement instrument's stability over the test-retest intervals. There were statistically significant positive correlations between the DASS-21 Depression subscale and both the CES-D-20 (r\u0026thinsp;=\u0026thinsp;0.702) and the GHQ-28 Depression (r\u0026thinsp;=\u0026thinsp;0.755). The DASS-21 Anxiety subscale showed strong positive correlations with the CES-D-20 (r\u0026thinsp;=\u0026thinsp;0.622) and the GHQ-28 Anxiety (r\u0026thinsp;=\u0026thinsp;.659). The DASS-21 Stress subscale also exhibited comparable positive associations with the CES-D-20 (r\u0026thinsp;=\u0026thinsp;0.700) and the GHQ-28 Anxiety (r\u0026thinsp;=\u0026thinsp;0.663). Also, the DASS-21 Depression subscale demonstrated a strong positive correlation with both the DASS-21 Anxiety (r\u0026thinsp;=\u0026thinsp;0.780) and the DASS-21 Stress (r\u0026thinsp;=\u0026thinsp;0.806) subscales. Meanwhile, all subscales, along with the overall DASS-21, exhibited favorable fit indices, thereby supporting the proposed factor structure.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe Pashto version of DASS-21 is proven to be a reliable and valid instrument to assess the magnitude of depression, anxiety, and stress among the Pashto-speaking Afghan adult population in Kandahar and Helmand provinces. The Pashto version of the DASS-21 will allow Afghan clinicians and researchers to screen common mental health disorders among the Pashto-speaking Afghan population.\u003c/p\u003e","manuscriptTitle":"Validation of the Pashto version of the 21-item Depression, Anxiety, and Stress Scale (DASS-21) among Afghans","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 09:06:41","doi":"10.21203/rs.3.rs-7433674/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5b27e12a-24df-40c4-8f0d-efba1d76ad7e","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-25T09:27:16+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-16 09:06:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7433674","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7433674","identity":"rs-7433674","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}