Validation of the Generalized Anxiety Disorder Screener (GAD-7) in Cypriot Pregnant and Postpartum Women

Validation of the Generalized Anxiety Disorder Screener (GAD-7) in Cypriot Pregnant and Postpartum Women | 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 Generalized Anxiety Disorder Screener (GAD-7) in Cypriot Pregnant and Postpartum Women Paris Vogazianos, Emma Motrico, Sara Domínguez-Salas, Andri Christoforou, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1551180/v2 This work is licensed under a CC BY 4.0 License Status: Under Review Version 2 posted 10 You are reading this latest preprint version Show more versions Abstract Background Anxiety is increasingly acknowledged as a common mental health issue during the perinatal period. Its prevalence as well as the associated adverse effects constitute screening imperative. This study evaluates the psychometric properties and underlying factor structures of a Greek version of GAD-7 among pregnant and postpartum women (up to 6 months) in Cyprus. Methods This study was conducted from June to December 2020. A total of 457 Cypriot women in the perinatal period (222 pregnant and 235 postpartum) were surveyed. The assessment included anxiety (GAD-7) and depression (EPDS), and psychosocial factors related with anxiety. The internal consistency and factor structure of GAD-7 were evaluated using reliability coefficients, Cronbach’s Alpha and McDonald's Omega, and factor analysis, both Exploratory as well as Confirmatory. Results GAD-7 demonstrated good internal consistency (α = 0.907; Ω = 0.909). Horn's parallel analysis indicated a single factor as the most appropriate. EFA for a single factor gave KMO = 0.917 and Bartlett’s sphericity test, p < 0.001. CFA using the standard ML method indicated a good model fit, χ 2 = 21.207, p = 0.096; CFI = 0.999; SRMR = 0.027. More studies are needed to determinate the cut-off point and the maximisation of the scale’s sensitivity and specificity in pregnant and postpartum Greek Cypriot women Conclusions GAD-7 is a valid and reliable measure and healthcare professionals should utilize GAD-7 as a standard instrument for the screening of anxiety symptoms in pregnant and postpartum Greek Cypriot women. GAD-7 anxiety perinatal anxiety pregnancy postpartum Background Perinatal anxiety has been receiving growing attention in the literature in recent years. A systematic review and meta-analysis of 102 studies with 221,974 women from 34 countries estimated that the prevalence for self-reported anxiety symptoms was 18.2% in the first trimester, 19.1% in the second trimester, 24.6% in the third trimester, and 15% at 1–24 weeks postpartum [ 1 ]. A recent meta-analysis by Fawcett et al. [ 2 ] suggests that 1 in 5 women in the perinatal period meet the diagnostic criteria for at least one anxiety disorder, constituting anxiety disorders with perinatal onset much more prevalent than previously thought. While significant differences in study methodology result in a wide variation in the estimates of anxiety-related disorders or symptoms [ 3 , 4 ], it is now well-established that the prevalence of anxiety warrants clinical attention [ 1 , 2 , 5 ]. In addition, the association of perinatal anxiety with adverse consequences on birth and neonatal outcomes [ 6 , 7 , 8 ], mother-infant relationship [ 9 , 10 ], as well as the association with postpartum depression [ 11 , 12 ] constitute screening imperative. The National Institute for Health and Care Excellence [ 13 ] states that the range and prevalence of anxiety disorders are under-recognised both during pregnancy and the postpartum period. The American College of Obstetricians and Gynecologists [ 14 ] recommends that women in the perinatal period are screened at least once for depression and anxiety symptoms through standardized, validated tools. More than ever, routine screening for anxiety, depression, and other mental health issues becomes of utmost importance under the current circumstances of COVID-19 pandemic [ 15 , 16 ]. Proactive measures could result in prevention, early detection, and prompt referral and treatment [ 17 ]. The Generalized Anxiety Disorder-7 (GAD-7), developed by Spitzer et al. [ 18 ], is one of the recommended screening measures for perinatal anxiety by NICE [ 13 ], although it is recommended for further assessment in case a woman scores 3 or more on the GAD-2, a distinct subscale comprising of the first two GAD-7 items, whose usefulness in maternity services has been debated [ 19 ]. A recent study by Fairbrother et al. [ 20 ] showed that GAD-7 outperformed the GAD-2 in their sample of 310 Canadian at 3-months postpartum. The GAD-7 has been found to have good psychometric properties among other populations in the perinatal period such as English-speaking perinatal women in Canada [ 21 ], Spanish-speaking pregnant Peruvian women [ 22 ], Spanish-speaking pregnant women in urban Spain [ 23 ], and pregnant Chinese women in mainland China [ 24 ]. The aim of the present article is to examine the psychometric properties and the factor structure of the GAD-7 in a sample of Cypriot pregnant and postpartum women. So far, there are no published studies of the properties of the GAD-7 in Cypriot women in the perinatal period. Methods Study Design Our sample consisted of 457 Cypriot women in the perinatal period (222 pregnant and 235 postpartum) who were recruited in the framework of the international study “Impact of the Covid-19 pandemic on perinatal mental health (Riseup-PPD-COVID-19)” (Identifier: NCT04595123) [ 25 ]. The data presented here are extracted from the baseline assessment, which was conducted in the period between July 2020 and January 2021. The inclusion criteria at baseline were: (i) Pregnant or biological mother of a child six months old or younger; (ii) 18 years of age or older and (iii) Living in Cyprus. The study was conducted according to the principles expressed in the Declaration of Helsinki, whereas ethical approval for the data collection in Cyprus was obtained by the Cyprus National Bioethics Committee (ΕΕΒΚ ΕΠ 2020.01.Ι26). Electronic informed consent was obtained from all the participants, and the confidentiality of all information provided was ensured. Handling of the study data complies with all the national required standards for data protection. Study Sample and Procedure Participants were recruited mainly through social media (Facebook, Instagram), through local organizations and maternity units in both public and private hospitals, as well as through personal networks of colleagues and acquaintances of the research team members. Data collection was implemented through Qualtrics®. Women who fulfilled the inclusion criteria were asked to click on the project website link ( https://momsduringcovid.org/cyprus ) so that they would be directed to the online questionnaire for Cyprus. After an overview of the study, participants were asked to confirm the set of eligibility criteria and to provide their consent to access the study. The Informed Consent provided a clear explanation of how anonymity, confidentiality and protection of data would be safeguarded. A debriefing procedure was also in place, where a list of relevant up-to-date psychosocial services and resources in Cyprus was provided to the participants at the end of the survey. The questionnaire, which consisted of several different scales as described in Motrico et al. [ 25 ], was available in both Greek and English languages as the study targeted all women living in Cyprus with the characteristics mentioned above. The Greek translation of GAD-7 was performed following the three steps proposed by Fenn et al. [ 26 ]: (a) forward translation by at least two translators working separately (b) backward translation by at least two translators working separately, (c) check by committee of experts. The English GAD-7 was initially translated in Greek by two independent experts who were fluent in the original and target languages and cultures – one language expert and one subject expert – who worked separately and produced two translations. The two versions were compared and the minor discrepancies found were discussed and resolved. The agreed Greek version was then translated back into English by a competent language expert and a subject expert who were not involved in the forward translation. After the research team ensured that the backward translation matched the original English version and a consensus was reached to ensure that the final Greek version was equivalent in language and meaning to the English version, the measure, along with the rest of the questionnaire, was pilot tested to ensure adaptability the Greek-speaking Cypriot population. Based on the diagnostic criteria for generalized anxiety disorder as established in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders [ 27 ], the GAD-7 is a seven item self-report measure asking about core generalized anxiety disorder symptoms experienced in the previous two weeks. Each item is rated on a four-point scale (0 = Not at all and 3 = Nearly every day) and total scores range from 0 to 21 (Spitzer et al., 2006). To the best of our knowledge, this is the first study that investigates the psychometric properties and factor structure of the GAD-7 in a Greek-speaking sample of Cypriot women in the perinatal period. After the completion of the baseline assessment, survey data were manually checked for accuracy and consistency before analysis. From an initial number of 1172 respondents, 477 invalid records were identified and removed because either the participant indicated erroneous pregnancy duration or their baby was over 6 months. The data of women who completed the Greek version but were not of Cypriot origin or had not specified origin (N = 238) were excluded from this analysis. The sample consisted of a total of 457 women who completed the Greek version of the questionnaire and who were of Cypriot origin. The statistical package SPSS v 26.0 was used for the analysis of data. Statistical Analysis All numerical variables were described using means ( \(\underset{\_}{x}\) ), medians (δ) and standard deviations (s) whereas all categorical variables were described using frequencies (f) and proportions (%). The distribution of all numerical variables was investigated through the Kolmogorov Smirnov test of Normality using R and since normality was rejected (p < 0.001) the differences between independent groups was examined through Mann Whitney test of independent groups using R. The internal consistency of GAD-7 was evaluated using both Cronbach’s Alpha as well as McDonalds’ Ordinal Omega due to a possible skewed distribution of the data [ 28 , 29 ] using SPSS version 26 with Hayes Omega Macro [ 30 ] and through Polychoric Correlations of the items between themselves [ 31 ], calculated using the ‘Polycor’ library in R. The associations between GAD-7 and other variables – namely level of stress related to the COVID-19 outbreak, depression symptoms, and PTSD symptoms – were examined using Spearman’s correlation and Polychoric Correlations calculated using the ‘Polycor’ library in R. The association of GAD-7 and receiving treatment for mental health concerns was examined through Mann Whitney test of independent groups using R. The factor structure of GAD-7 was examined through Horn's Parallel Analysis for factor retention [ 32 ] calculated using the ‘Paran’ library in R, Exploratory Factor Analysis (EFA) was performed using the ordered argument of ‘Lavan’ library in R and Confirmatory Factor Analyses (CFA) was calculated using SPSS version 26. Since the standard Maximum Likelihood (ML) method in the CFA analysis assumes a continuous and multivariate normal distribution, the Robust Maximum Likelihood (MLR) was also used in case this normality assumption was violated [ 33 ]. In the CFA analysis, to correctly evaluate the fit of a model, we used multiple indexes [34, 35, 36, 37, 38) such as the model chi-square (χ 2 ), the model standardised chi-square (χ 2 /df), the Comparative Fit Index (CFI), the Root Means Square Error of Approximation (RMSEA), the Standardized Root Mean Square Residual (SRMR) and the Tucker-Lewis Index (TLI). The cut-off points, for the fit indices, for a good fit according to Hu, & Bentler, [ 39 ] are CFI ≥ 0.95; TLI ≥ 0.95; SRMR ≤ 0.08; RMSEA ≤ 0.06 whereas according to Browne & Cudeck, [ 40 ] and MacCallum, Browne & Sugawara, [ 41 ], 0.06 ≤ RMSEA ≤ 0.1 suggest an adequate fit. Finally, according to Cole, [ 42 ] the χ 2 , and χ 2 /df should not be significant. Results The study sample consisted of 222 pregnant and 235 postpartum women (with infants up to 6 months of age). For 60.6% of the participants, this was their first pregnancy (59.5% of pregnant women and 61.7% of postpartum women). The rest of demographic characteristics of the sample are described in Table 1 . Table 1 Demographic characteristics N % Age 18–25 9 2.0 26–35 311 68.1 36–45 111 24.3 Did not respond 26 5.7 Highest level of education Secondary school/ High school 21 4.6 Partial university studies 26 5.5 University studies (undergraduate) 173 37.9 Master or Doctorate 234 51.2 Other 3 0.7 Relationship status Single 2 0.4 Partnered/engaged or living as a couple 77 16.8 Married 375 82.1 Separated or divorced 3 0.7 Residence Owned (paid in full) 200 43.8 Owned (paying mortgage) 101 22.1 Rented 107 23.4 Living with parents 31 6.8 Living with others 9 1.9 Other 9 2.0 Individual item means, standard deviations, item-total correlations, and Cronbach’s alphas with items removed are presented in Table 2 . The Kolmogorov Smirnov test of Normality indicated a lack of Normality in the overall GAD-7 (p < 0.001) whereas the Mann Witney test of independent groups indicated non-statistically significant tests between pregnant women and new mothers (p = 0.291). Table 2 GAD-7 Item Means, Medians, Standard Deviations, Skewness, Kurtosis, Corrected Item-Total Correlations (r), Cronbach’s Alpha with Item Removed (α), Factor Loadings, and Communalities Item Q1 Q2 Q3 Q4 Q5 Q6 Q7 Mean 0.71 0.50 0.84 0.89 0.43 0.84 0.56 Median 0.00 0.00 1.00 1.00 0.00 1.00 0.00 SD 0.88 0.78 0.86 0.91 0.76 0.88 0.79 Skewness 1.19 1.57 0.95 0.88 1.88 1.01 1.53 Kurtosis 0.69 1.81 0.38 0.06 3.11 0.47 2.00 r 0.76 0.81 0.79 0.74 0.75 0.68 0.54 α 0.89 0.88 0.89 0.89 0.89 0.90 0.91 Factor loading 0.82 0.87 0.83 0.78 0.79 0.72 0.56 Communalities 0.66 0.76 0.68 0.60 0.63 0.51 0.32 The internal consistency of the GAD-7 was high (Cronbach’s Alpha = 0.907 and MacDonald’s Ordinal Omega = 0.909). An examination of the response categories of the seven items on the GAD-7 indicate that results were mainly distributed in the lowest answer categories for each item. There was mainly a tendency towards a floor effect in questions 5 (Intense nervousness, to the point that you cannot stay calm) and 2 (Inability to calm down or control your worries), with an 69.1% and a 64.8% accumulation of answers on the lowest rating (“not at all”). All the items’ percentages of respondents for each answer in each item are shown on Table 3 . A floor effect was also available in items 1 (Nervousness, anxiety or agitation) and 7 (Fear that something tragic will happen) as indicated by the median answers (δ = 0). Table 3 Percentages of respondents for each answer in each item of GAD-7 Item Q1 Q2 Q3 Q4 Q5 Q6 Q7 0 51.0 64.8 39.8 38.5 69.1 39.8 58.6 1 33.9 24.1 43.3 41.8 22.1 44.0 31.7 2 8.5 7.9 10.3 11.4 5.0 8.3 5.0 3 6.6 3.3 6.6 8.3 3.7 7.9 4.6 The correlation between the GAD-7 items ranged from 0.85 to 0.47 (Table 4 ). Table 4 Polychoric correlations of the GAD 7 scale items Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q1 1.00 Q2 0.85 1.00 Q3 0.75 0.85 1.00 Q4 0.68 0.76 0.77 1.00 Q5 0.79 0.81 0.76 0.77 1.00 Q6 0.72 0.71 0.66 0.67 0.72 1.00 Q7 0.53 0.58 0.64 0.53 0.55 0.47 1.00 GAD-7 had significant correlations with all of the variables examined for construct validity (p < 0.001) with Polychoric correlations ranging from a maximum of 0.767 and 0.759 (with PTSD total and EPDS respectively) to a minimum of 0.326 (with PTSD9) and the Spearman’s correlations ranging from a maximum of 0.747 and 0.744 (with PTSD total and EPDS respectively) to a minimum of 0.180 (with PTSD10) (Table 5 ). Similarly, the participants who reported receiving treatment for mental health concerns at the time of the study had significantly (p = 0.009) higher levels of GAD-7 ( \(\underset{\_}{x}=7.56, \sigma =5.14,\) δ = 7) versus the participants not receiving treatment (median value of ( \(\underset{\_}{x}=4.66, \sigma =4.65,\) δ = 3). Table 5 Associations between GAD-7 and Other Variables Polychoric Correlations Spearman's Correlations Mann Whitney U p value Receiving treatment 2181.5 0.009 # LEVEL OF STRESS 0.514 0.482 < 0.001 * EPDS 0.759 0.744 < 0.001 * PTSD1 0.668 0.604 < 0.001 * PTSD2 0.508 0.414 < 0.001 * PTSD3 0.660 0.581 < 0.001 * PTSD4 0.710 0.613 < 0.001 * PTSD5 0.661 0.523 < 0.001 * PTSD6 0.672 0.611 < 0.001 * PTSD7 0.513 0.466 < 0.001 * PTSD8 0.459 0.303 < 0.001 * PTSD9 0.326 0.291 < 0.001 * PTSD10 0.357 0.180 < 0.001 * PTSD Total 0.767 0.747 < 0.001 * * Based on the Spearman’s Correlations # Based on the Mann Whitney U test of independent groups Optimal implementation of Horn's parallel analysis was carried out, using the eigen decomposition of correlation matrix, to determine the most appropriate number of factors. The results advocate in favour of extracting a single factor because the adjusted eigen value was greater than 0 (Table 6 ). Table 6 Optimal implementation of parallel analysis with 5000 iterations, using the mean estimate Factor Adjusted Eigenvalue Unadjusted Eigenvalue Estimated Bias 1 3.924711 4.120452 0.195741 2 -0.022972 0.094691 0.117663 3 -0.050621 0.007501 0.058123 4 -0.029775 -0.02341 0.006356 5 -0.000459 -0.04215 -0.04169 6 -0.023827 -0.11608 -0.09225 7 0.013873 -0.13773 -0.1516 Adjusted eigenvalues > 0 indicate dimensions to retain. (1 factor retained) Exploratory Factor Analysis (EFA) for a single factor which is both the most common used structure GAD-7 as well as the structure advocated by the Horn's parallel analysis was performed (Kaiser-Meyer-Olkin (KMO) test = 0.917, Bartlett’s sphericity test, χ 2 = 1908.545, df = 21, p < 0.001) using the Unweighted Least Squares (ULS) procedure for factor extraction with 59.6% of the total variance explained (Table 6 ). The confirmatory factor analysis (CFA) testing using the standard maximum likelihood method and the one-factor structure indicated a good model fit, χ 2 = 21.207, p = 0.096; χ 2 /df = 1.51, p = 0.218; CFI = 0.999; TLI = 0.999; RMSEA = 0.034, p = 0.818; SRMR = 0.027 (see Table 5 ) where all the cut off points, for a good fit, were adhered. On the other hand, the confirmatory factor analysis (CFA) testing using the robust maximum likelihood method and the one-factor structure indicated an acceptable model fit, χ 2 = 53.899, p < 0.001; χ 2 /df = 3.85, p = 0.0497; CFI = 0.994; TLI = 0.991, RMSEA = 0.079, p = 0.015; SRMR = 0.027 (see Table 5 ) where the cut off points for CFI, TLI and SRMR suggest a good fit, RMSEA and χ 2 /df suggest an adequate fit, whereas the χ 2 was not adhered. Discussion The present study is the first to examine the psychometric properties and factor structure of the GAD-7 in a sample of Greek-speaking pregnant and postpartum Cypriot women. The internal consistency of the GAD-7 was high (Cronbach’s Alpha = 0.907 and MacDonald’s Ordinal Omega = 0.909), while the correlation between the GAD-7 items ranged from 0.85 to 0.47. Our results indicated no significant differences between pregnant (N = 222) and postpartum (N = 235) women (p = 0.291). Correlations between GAD-7 and overall levels of stress, depression symptoms, and PTSD symptoms were all positive and significant (p < 0.001), while the participants reporting receiving treatment for mental health concerns at the time of the study had significantly higher (p = 0.009) GAD-7 results than the rest of the participants. Horn's parallel analysis supported the extraction of a single factor as optimal. Exploratory Factor Analysis for a single factor was performed with KMO = 0.917, Bartlett’s sphericity test, χ 2 = 1908.545, df = 21, p < 0.001 and 59.6% of the total variance explained. Confirmatory factor analysis using the standard ML method indicated a good model fit, χ 2 = 21.207, p = 0.096; χ 2 /df = 1.51, p = 0.218; CFI = 0.999; TLI = 0.999; RMSEA = 0.034, p = 0.818; SRMR = 0.027 whereas confirmatory factor analysis using the robust ML method indicated an acceptable model fit, χ 2 = 53.899, p < 0.001; χ 2 /df = 3.85, p = 0.0497; CFI = 0.994; TLI = 0.991, RMSEA = 0.079, p = 0.015; SRMR = 0.027. Our findings strengthen the evidence for the use of GAD-7 as a brief screening measure for anxiety in the perinatal period [ 21 , 22 , 24 , 23 , 43 ]. Another strength of the present study is that the results are based on women who span a spectrum of the perinatal period, namely early pregnancy until 6 months postpartum, unlike other studies which focused only on pregnancy [ 22 , 23 ] or on even more specific periods, such as the first trimester [ 24 ]. As NICE’s (2014)[ 13 ] recommendations for the use of GAD-2 and GAD-7 were mainly based on expert consensus rather than research findings [ 19 ], this study fills a gap in the literature, contributing further to the validation of GAD-7 in the perinatal population. It also contributes to the debate in recent literature [ 20 ] providing evidence for the usefulness of GAD-7 in screening for anxiety during pregnancy and up to 6 months postpartum. The major limitation of this study is the lack of data from other self-report anxiety measures and perhaps more importantly, the lack of data obtained through gold standard methodology, i.e. through well-validated diagnostic structures such as clinical interviews [ 22 , 24 ]. The study design did not allow us, therefore, to utilize a cut-off point and maximize the sensitivity and specificity. Nevertheless, the study results provide evidence that GAD-7 can be used as a first screening measure of perinatal anxiety, both for prevention purposes and also for further follow ups including diagnostic interviews and interventions if warranted. It is important to highlight, however, that further validation studies in different socio-cultural contexts are needed if GAD-7 is intended for use in clinical practice with perinatal populations. As a validation study with pregnant women from Ghana and Côte d’Ivoire [ 44 ] suggests, GAD-7 may perform better in higher-income countries. Conclusion In summary, the present study indicates that the excellent psychometric properties of GAD-7 for Greek Cypriot pregnant and postpartum women (up to 6 months) constitute GAD-7 an appropriate brief screener for anxiety in the perinatal period. As such, it can be incorporated into standard practice of intrapartum care in Cyprus for the prevention and treatment of anxiety as necessary. These research findings are especially relevant for clinicians and mental health professionals working with women in the perinatal period, and particularly those who are at risk of developing or having pre-existing anxiety symptoms. Declarations Ethics approval and consent to participate The study has been approved by the Cyprus National Bioethics Committee (ΕΕΒΚ ΕΠ 2020.01.Ι26). Consent for publication Not Applicable Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due ethical restrictions but are available from the corresponding author on reasonable request. Competing interests None of the manuscript authors is in a position of conflict of interest in any respect. Funding Not Applicable Authors' contributions P.V. conceived and executed the analysis presented in this article. E.M. and S.D. conceived the overall study and took the lead in developing the design. E.H. and A.C. participated in study design and took the lead in executing the study design (recruitment, data collection, study management) in Cyprus. P.V., A.C. and E.H. had the overall responsibility for manuscript planning and preparation. All authors read, edited and approved the final submission. Acknowledgements This article is based upon work from COST Action CA18138 "Research Innovation and Sustainable Pan-European Network in Peripartum Depression Disorder" (Riseup-PPD), supported by COST (European Cooperation in Science and Technology;https://www.cost.eu/ We would like to thank the women who participated in this study for the generous contribution of their time. References Dennis CL, Falah-Hassani K, Shiri R. Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis. The British Journal of Psychiatry. 2017 May;210(5):315-23. https://doi.org/10.1192/bjp.bp.116.187179 Fawcett EJ, Fairbrother N, Cox ML, White IR, Fawcett JM. 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Psicothema. 2021. https://doi.org/10.7334/psicothema2020.167 Gong Y, Zhou H, Zhang Y, Zhu X, Wang X, Shen B, Xian J, Ding Y. Validation of the 7-item Generalized Anxiety Disorder scale (GAD-7) as a screening tool for anxiety among pregnant Chinese women. Journal of affective disorders. 2021 Mar 1;282:98-103. https://doi.org/10.1016/j.jad.2020.12.129 Motrico E, Bina R, Domínguez-Salas S, Mateus V, Contreras-García Y, Carrasco-Portiño M, Ajaz E, Apter G, Christoforou A, Dikmen-Yildiz P, Felice E. Impact of the Covid-19 pandemic on perinatal mental health (Riseup-PPD-COVID-19): protocol for an international prospective cohort study. BMC Public Health. 2021 Dec;21(1):1-1.https://doi.org/10.1186/s12889-021-10330-w Fenn J, Tan CS, George S. Development, validation and translation of psychological tests. BJPsych Advances. 2020 Sep;26(5):306-15. https://doi.org/10.1192/bja.2020.33 Bell CC. DSM-IV: diagnostic and statistical manual of mental disorders. Jama. 1994 Sep 14;272(10):828-9. Zinbarg RE, Revelle W, Yovel I, Li W. Cronbach’s α, Revelle’s β, and McDonald’s ω H: Their relations with each other and two alternative conceptualizations of reliability. psychometrika. 2005 Mar;70(1):123-33. https://doi.org/10.1007/s11336-003-0974-7 Trizano-Hermosilla I, Alvarado JM. Best alternatives to Cronbach's alpha reliability in realistic conditions: congeneric and asymmetrical measurements. Frontiers in psychology. 2016 May 26;7:769. https://doi.org/10.3389/fpsyg.2016.00769 Hayes AF, Coutts JJ. Use omega rather than Cronbach’s alpha for estimating reliability. But…. Communication Methods and Measures. 2020 Jan 2;14(1):1-24. https://doi.org/10.1080/19312458.2020.1718629 Choi J, Peters M, Mueller RO. Correlational analysis of ordinal data: from Pearson’sr to Bayesian polychoric correlation. Asia Pacific education review. 2010 Dec;11(4):459-66. https://doi.org/10.1007/s12564-010-9096-y Dinno A. Implementing Horn's parallel analysis for principal component analysis and factor analysis. The Stata Journal. 2009 Aug;9(2):291-8. https://doi.org/10.1177/1536867X0900900207 Li CH. Confirmatory factor analysis with ordinal data: Comparing robust maximum likelihood and diagonally weighted least squares. Behavior research methods. 2016 Sep;48(3):936-49. https://doi.org/10.3758/s13428-015-0619-7 Ullman JB, Bentler PM. Structural equation modeling. Handbook of Psychology, Second Edition. 2012 Sep 26;2. West SG, Taylor AB, Wu W. Model fit and model selection in structural equation modeling. Handbook of structural equation modeling. 2012;1:209-31. Byrne BM. Factor analytic models: Viewing the structure of an assessment instrument from three perspectives. Journal of personality assessment. 2005 Aug 1;85(1):17-32. https://doi.org/10.1207/s15327752jpa8501_02 Hoyle RH. Confirmatory factor analysis. InHandbook of applied multivariate statistics and mathematical modeling 2000 Jan 1 (pp. 465-497). Academic Press. Sun J. Assessing goodness of fit in confirmatory factor analysis. Measurement and evaluation in counseling and development. 2005 Jan 1;37(4):240-56. https://doi.org/10.1080/07481756.2005.11909764 Hu LT, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural equation modeling: a multidisciplinary journal. 1999 Jan 1;6(1):1-55. https://doi.org/10.1080/10705519909540118 Browne MW, Cudeck R. Alternative ways of assessing model fit. Sociological methods & research. 1992 Nov;21(2):230-58.https://doi.org/10.1177/0049124192021002005 MacCallum RC, Browne MW, Sugawara HM. Power analysis and determination of sample size for covariance structure modeling. Psychological methods. 1996 Jun;1(2):130. Cole DA. Utility of confirmatory factor analysis in test validation research. Journal of consulting and clinical psychology. 1987 Aug;55(4):584.https://doi.org/10.1037/0022-006X.55.4.584 Sinesi A, Maxwell M, O'Carroll R, Cheyne H. Anxiety scales used in pregnancy: systematic review. BJPsych open. 2019 Jan;5(1). https://doi.org/10.1192/bjo.2018.75 Barthel D, Barkmann C, Ehrhardt S, Bindt C, International CDS Study Group. Psychometric properties of the 7-item Generalized Anxiety Disorder scale in antepartum women from Ghana and Côte d’Ivoire. Journal of Affective Disorders. 2014 Dec 1;169:203-11. https://doi.org/10.1016/j.jad.2014.08.004. Additional Declarations No competing interests reported. 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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-1551180","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[{"code":1,"date":"2022-05-03 16:46:32","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}}],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":123816476,"identity":"ad0dcfbd-8a00-4d36-9be2-ff7ff8bb836b","order_by":0,"name":"Paris Vogazianos","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIiWNgGAWjYBADHjD5gWQtjDNItoqZhxhV5gw8hg+/1NTJ8M9uPvzZpuKwPAP74QcMP9twa7Fs4DE2ljnGxiNx51iadM6Zw4YNPGkGjL14tBgcYEuTlmDj4WG4kWPGnNt2OIGBIYeBmZGgln8SPPI3cow/W/4DauF/Q0gL8zHJj20GPAY3cgykGRuAWiQI2GLZzHzYmLEvgcfwRlqaZM+xdMM2iWcGB3vO4dZizt7Y+PDHtzp7uRvJhz/8qLGW5+dPfvjgRxkehzGjRwcbEB9gZMOjBYgZf2CK/8GtZRSMglEwCkYcAACfckeUSTyGSAAAAABJRU5ErkJggg==","orcid":"","institution":"European University Cyprus","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Paris","middleName":"","lastName":"Vogazianos","suffix":""},{"id":123816477,"identity":"a060443a-59c0-4caa-82f0-f01577e4884d","order_by":1,"name":"Emma Motrico","email":"","orcid":"","institution":"Universidad Loyola Andalucia","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Emma","middleName":"","lastName":"Motrico","suffix":""},{"id":123816478,"identity":"1a8b3e7e-c1a9-41f4-a5b3-687786396c9c","order_by":2,"name":"Sara Domínguez-Salas","email":"","orcid":"","institution":"Universidad Loyola Andalucia","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sara","middleName":"","lastName":"Domínguez-Salas","suffix":""},{"id":123816479,"identity":"7e153162-f6ab-4193-a945-acc1326a0f06","order_by":3,"name":"Andri Christoforou","email":"","orcid":"","institution":"European University Cyprus","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Andri","middleName":"","lastName":"Christoforou","suffix":""},{"id":123816480,"identity":"f47ddb31-2763-45a3-9f81-c918b15884d8","order_by":4,"name":"Eleni Hadjigeorgiou","email":"","orcid":"","institution":"Cyprus University of Technology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Eleni","middleName":"","lastName":"Hadjigeorgiou","suffix":""}],"badges":[],"createdAt":"2022-04-12 16:14:03","currentVersionCode":2,"declarations":"","doi":"10.21203/rs.3.rs-1551180/v2","doiUrl":"https://doi.org/10.21203/rs.3.rs-1551180/v2","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":24349776,"identity":"133b6410-3a55-4e07-8b1a-12b825227161","added_by":"auto","created_at":"2022-07-26 15:14:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":344767,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1551180/v2/ca031b1e-0455-41dc-a533-a02aad301a57.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Validation of the Generalized Anxiety Disorder Screener (GAD-7) in Cypriot Pregnant and Postpartum Women","fulltext":[{"header":"Background","content":"\u003cp\u003ePerinatal anxiety has been receiving growing attention in the literature in recent years. A systematic review and meta-analysis of 102 studies with 221,974 women from 34 countries estimated that the prevalence for self-reported anxiety symptoms was 18.2% in the first trimester, 19.1% in the second trimester, 24.6% in the third trimester, and 15% at 1\u0026ndash;24 weeks postpartum [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. A recent meta-analysis by Fawcett et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] suggests that 1 in 5 women in the perinatal period meet the diagnostic criteria for at least one anxiety disorder, constituting anxiety disorders with perinatal onset much more prevalent than previously thought. While significant differences in study methodology result in a wide variation in the estimates of anxiety-related disorders or symptoms [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], it is now well-established that the prevalence of anxiety warrants clinical attention [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In addition, the association of perinatal anxiety with adverse consequences on birth and neonatal outcomes [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], mother-infant relationship [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], as well as the association with postpartum depression [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] constitute screening imperative.\u003c/p\u003e \u003cp\u003eThe National Institute for Health and Care Excellence [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] states that the range and prevalence of anxiety disorders are under-recognised both during pregnancy and the postpartum period. The American College of Obstetricians and Gynecologists [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] recommends that women in the perinatal period are screened at least once for depression and anxiety symptoms through standardized, validated tools. More than ever, routine screening for anxiety, depression, and other mental health issues becomes of utmost importance under the current circumstances of COVID-19 pandemic [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Proactive measures could result in prevention, early detection, and prompt referral and treatment [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Generalized Anxiety Disorder-7 (GAD-7), developed by Spitzer et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], is one of the recommended screening measures for perinatal anxiety by NICE [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], although it is recommended for further assessment in case a woman scores 3 or more on the GAD-2, a distinct subscale comprising of the first two GAD-7 items, whose usefulness in maternity services has been debated [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A recent study by Fairbrother et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] showed that GAD-7 outperformed the GAD-2 in their sample of 310 Canadian at 3-months postpartum. The GAD-7 has been found to have good psychometric properties among other populations in the perinatal period such as English-speaking perinatal women in Canada [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], Spanish-speaking pregnant Peruvian women [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], Spanish-speaking pregnant women in urban Spain [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], and pregnant Chinese women in mainland China [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe aim of the present article is to examine the psychometric properties and the factor structure of the GAD-7 in a sample of Cypriot pregnant and postpartum women. So far, there are no published studies of the properties of the GAD-7 in Cypriot women in the perinatal period.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eOur sample consisted of 457 Cypriot women in the perinatal period (222 pregnant and 235 postpartum) who were recruited in the framework of the international study \u0026ldquo;Impact of the Covid-19 pandemic on perinatal mental health (Riseup-PPD-COVID-19)\u0026rdquo; (Identifier: NCT04595123) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The data presented here are extracted from the baseline assessment, which was conducted in the period between July 2020 and January 2021. The inclusion criteria at baseline were: (i) Pregnant or biological mother of a child six months old or younger; (ii) 18 years of age or older and (iii) Living in Cyprus. The study was conducted according to the principles expressed in the Declaration of Helsinki, whereas ethical approval for the data collection in Cyprus was obtained by the Cyprus National Bioethics Committee (ΕΕΒΚ ΕΠ 2020.01.Ι26). Electronic informed consent was obtained from all the participants, and the confidentiality of all information provided was ensured. Handling of the study data complies with all the national required standards for data protection.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Sample and Procedure\u003c/h2\u003e \u003cp\u003eParticipants were recruited mainly through social media (Facebook, Instagram), through local organizations and maternity units in both public and private hospitals, as well as through personal networks of colleagues and acquaintances of the research team members. Data collection was implemented through Qualtrics\u0026reg;. Women who fulfilled the inclusion criteria were asked to click on the project website link (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://momsduringcovid.org/cyprus\u003c/span\u003e\u003cspan address=\"https://momsduringcovid.org/cyprus\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) so that they would be directed to the online questionnaire for Cyprus. After an overview of the study, participants were asked to confirm the set of eligibility criteria and to provide their consent to access the study. The Informed Consent provided a clear explanation of how anonymity, confidentiality and protection of data would be safeguarded. A debriefing procedure was also in place, where a list of relevant up-to-date psychosocial services and resources in Cyprus was provided to the participants at the end of the survey.\u003c/p\u003e \u003cp\u003eThe questionnaire, which consisted of several different scales as described in Motrico et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], was available in both Greek and English languages as the study targeted all women living in Cyprus with the characteristics mentioned above. The Greek translation of GAD-7 was performed following the three steps proposed by Fenn et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]: (a) forward translation by at least two translators working separately (b) backward translation by at least two translators working separately, (c) check by committee of experts. The English GAD-7 was initially translated in Greek by two independent experts who were fluent in the original and target languages and cultures \u0026ndash; one language expert and one subject expert \u0026ndash; who worked separately and produced two translations. The two versions were compared and the minor discrepancies found were discussed and resolved. The agreed Greek version was then translated back into English by a competent language expert and a subject expert who were not involved in the forward translation. After the research team ensured that the backward translation matched the original English version and a consensus was reached to ensure that the final Greek version was equivalent in language and meaning to the English version, the measure, along with the rest of the questionnaire, was pilot tested to ensure adaptability the Greek-speaking Cypriot population.\u003c/p\u003e \u003cp\u003eBased on the diagnostic criteria for generalized anxiety disorder as established in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], the GAD-7 is a seven item self-report measure asking about core generalized anxiety disorder symptoms experienced in the previous two weeks. Each item is rated on a four-point scale (0\u0026thinsp;=\u0026thinsp;Not at all and 3\u0026thinsp;=\u0026thinsp;Nearly every day) and total scores range from 0 to 21 (Spitzer et al., 2006). To the best of our knowledge, this is the first study that investigates the psychometric properties and factor structure of the GAD-7 in a Greek-speaking sample of Cypriot women in the perinatal period.\u003c/p\u003e \u003cp\u003eAfter the completion of the baseline assessment, survey data were manually checked for accuracy and consistency before analysis. From an initial number of 1172 respondents, 477 invalid records were identified and removed because either the participant indicated erroneous pregnancy duration or their baby was over 6 months. The data of women who completed the Greek version but were not of Cypriot origin or had not specified origin (N\u0026thinsp;=\u0026thinsp;238) were excluded from this analysis. The sample consisted of a total of 457 women who completed the Greek version of the questionnaire and who were of Cypriot origin. The statistical package SPSS v 26.0 was used for the analysis of data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eAll numerical variables were described using means (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\underset{\\_}{x}\\)\u003c/span\u003e\u003c/span\u003e), medians (δ) and standard deviations (s) whereas all categorical variables were described using frequencies (f) and proportions (%). The distribution of all numerical variables was investigated through the Kolmogorov Smirnov test of Normality using R and since normality was rejected (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) the differences between independent groups was examined through Mann Whitney test of independent groups using R. The internal consistency of GAD-7 was evaluated using both Cronbach\u0026rsquo;s Alpha as well as McDonalds\u0026rsquo; Ordinal Omega due to a possible skewed distribution of the data [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] using SPSS version 26 with Hayes Omega Macro [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] and through Polychoric Correlations of the items between themselves [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], calculated using the \u0026lsquo;Polycor\u0026rsquo; library in R. The associations between GAD-7 and other variables\u003ca class=\"FNLink\" href=\"#Fn1\" id=\"#FNLinkFn1\"\u003e\u003c/a\u003e \u0026ndash; namely level of stress related to the COVID-19 outbreak, depression symptoms, and PTSD symptoms \u0026ndash; were examined using Spearman\u0026rsquo;s correlation and Polychoric Correlations calculated using the \u0026lsquo;Polycor\u0026rsquo; library in R. The association of GAD-7 and receiving treatment for mental health concerns was examined through Mann Whitney test of independent groups using R. The factor structure of GAD-7 was examined through Horn's Parallel Analysis for factor retention [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] calculated using the \u0026lsquo;Paran\u0026rsquo; library in R, Exploratory Factor Analysis (EFA) was performed using the ordered argument of \u0026lsquo;Lavan\u0026rsquo; library in R and Confirmatory Factor Analyses (CFA) was calculated using SPSS version 26. Since the standard Maximum Likelihood (ML) method in the CFA analysis assumes a continuous and multivariate normal distribution, the Robust Maximum Likelihood (MLR) was also used in case this normality assumption was violated [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In the CFA analysis, to correctly evaluate the fit of a model, we used multiple indexes [34, 35, 36, 37, 38) such as the model chi-square (χ\u003csup\u003e2\u003c/sup\u003e), the model standardised chi-square (χ\u003csup\u003e2\u003c/sup\u003e/df), the Comparative Fit Index (CFI), the Root Means Square Error of Approximation (RMSEA), the Standardized Root Mean Square Residual (SRMR) and the Tucker-Lewis Index (TLI). The cut-off points, for the fit indices, for a good fit according to Hu, \u0026amp; Bentler, [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] are CFI\u0026thinsp;\u0026ge;\u0026thinsp;0.95; TLI\u0026thinsp;\u0026ge;\u0026thinsp;0.95; SRMR\u0026thinsp;\u0026le;\u0026thinsp;0.08; RMSEA\u0026thinsp;\u0026le;\u0026thinsp;0.06 whereas according to Browne \u0026amp; Cudeck, [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] and MacCallum, Browne \u0026amp; Sugawara, [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], 0.06\u0026thinsp;\u0026le;\u0026thinsp;RMSEA\u0026thinsp;\u0026le;\u0026thinsp;0.1 suggest an adequate fit. Finally, according to Cole, [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] the χ\u003csup\u003e2\u003c/sup\u003e, and χ\u003csup\u003e2\u003c/sup\u003e/df should not be significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe study sample consisted of 222 pregnant and 235 postpartum women (with infants up to 6 months of age). For 60.6% of the participants, this was their first pregnancy (59.5% of pregnant women and 61.7% of postpartum women). The rest of demographic characteristics of the sample are described in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\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\u003eDemographic characteristics\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=\"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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u0026ndash;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.0\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\u003e26\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e311\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e68.1\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\u003e36\u0026ndash;45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24.3\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\u003eDid not respond\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHighest level of education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary school/ High school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.6\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\u003ePartial university studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.5\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\u003eUniversity studies (undergraduate)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e173\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e37.9\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\u003eMaster or Doctorate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e234\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51.2\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\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRelationship status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.4\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\u003ePartnered/engaged or living as a couple\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16.8\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\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e375\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e82.1\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\u003eSeparated or divorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOwned (paid in full)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43.8\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\u003eOwned (paying mortgage)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.1\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\u003eRented\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.4\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\u003eLiving with parents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.8\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\u003eLiving with others\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.9\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\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.0\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\u003eIndividual item means, standard deviations, item-total correlations, and Cronbach\u0026rsquo;s alphas with items removed are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The Kolmogorov Smirnov test of Normality indicated a lack of Normality in the overall GAD-7 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) whereas the Mann Witney test of independent groups indicated non-statistically significant tests between pregnant women and new mothers (p\u0026thinsp;=\u0026thinsp;0.291).\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\u003eGAD-7 Item Means, Medians, Standard Deviations, Skewness, Kurtosis, Corrected Item-Total Correlations (r), Cronbach\u0026rsquo;s Alpha with Item Removed (α), Factor Loadings, and Communalities\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=\"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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQ1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQ2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQ3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eQ4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eQ5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eQ6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eQ7\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkewness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKurtosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eα\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactor loading\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunalities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.32\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 internal consistency of the GAD-7 was high (Cronbach\u0026rsquo;s Alpha\u0026thinsp;=\u0026thinsp;0.907 and MacDonald\u0026rsquo;s Ordinal Omega\u0026thinsp;=\u0026thinsp;0.909). An examination of the response categories of the seven items on the GAD-7 indicate that results were mainly distributed in the lowest answer categories for each item. There was mainly a tendency towards a floor effect in questions 5 (Intense nervousness, to the point that you cannot stay calm) and 2 (Inability to calm down or control your worries), with an 69.1% and a 64.8% accumulation of answers on the lowest rating (\u0026ldquo;not at all\u0026rdquo;). All the items\u0026rsquo; percentages of respondents for each answer in each item are shown on Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. A floor effect was also available in items 1 (Nervousness, anxiety or agitation) and 7 (Fear that something tragic will happen) as indicated by the median answers (δ\u0026thinsp;=\u0026thinsp;0).\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\u003ePercentages of respondents for each answer in each item of GAD-7\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=\"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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQ1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQ2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQ3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eQ4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eQ5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eQ6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eQ7\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e39.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e38.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e69.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e39.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e58.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e41.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e22.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e44.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e31.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4.6\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 correlation between the GAD-7 items ranged from 0.85 to 0.47 (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\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\u003ePolychoric correlations of the GAD 7 scale items\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=\"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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQ1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQ2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQ3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eQ4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eQ5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eQ6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eQ7\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00\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\u003eQ2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.00\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\u003eQ3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \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\u003eQ4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \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\u003eQ5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \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\u003eQ6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.00\u003c/p\u003e \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\u003eQ7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.00\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\u003eGAD-7 had significant correlations with all of the variables examined for construct validity (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) with Polychoric correlations ranging from a maximum of 0.767 and 0.759 (with PTSD total and EPDS respectively) to a minimum of 0.326 (with PTSD9) and the Spearman\u0026rsquo;s correlations ranging from a maximum of 0.747 and 0.744 (with PTSD total and EPDS respectively) to a minimum of 0.180 (with PTSD10) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Similarly, the participants who reported receiving treatment for mental health concerns at the time of the study had significantly (p\u0026thinsp;=\u0026thinsp;0.009) higher levels of GAD-7 (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\underset{\\_}{x}=7.56, \\sigma =5.14,\\)\u003c/span\u003e\u003c/span\u003eδ\u0026thinsp;=\u0026thinsp;7) versus the participants not receiving treatment (median value of (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\underset{\\_}{x}=4.66, \\sigma =4.65,\\)\u003c/span\u003e\u003c/span\u003eδ\u0026thinsp;=\u0026thinsp;3).\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\u003eAssociations between GAD-7 and Other Variables\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePolychoric Correlations\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSpearman's Correlations\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMann Whitney U\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReceiving treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2181.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.009\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLEVEL OF STRESS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.514\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.482\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEPDS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.759\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.744\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTSD1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.668\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.604\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTSD2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.508\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.414\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTSD3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.660\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.581\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTSD4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.710\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.613\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTSD5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.661\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.523\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTSD6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.672\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.611\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTSD7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.513\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.466\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTSD8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.459\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.303\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTSD9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.326\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.291\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTSD10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.357\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePTSD Total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.767\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.747\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003e*\u003c/sup\u003e Based on the Spearman\u0026rsquo;s Correlations\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003e#\u003c/sup\u003e Based on the Mann Whitney U test of independent groups\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOptimal implementation of Horn's parallel analysis was carried out, using the eigen decomposition of correlation matrix, to determine the most appropriate number of factors. The results advocate in favour of extracting a single factor because the adjusted eigen value was greater than 0 (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOptimal implementation of parallel analysis with 5000 iterations, using the mean estimate\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\u003eFactor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdjusted Eigenvalue\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnadjusted Eigenvalue\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEstimated Bias\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.924711\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.120452\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.195741\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.022972\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.094691\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.117663\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.050621\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.007501\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.058123\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=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.029775\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.02341\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.006356\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=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.000459\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.04215\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.04169\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=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.023827\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.11608\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.09225\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=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.013873\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.13773\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.1516\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003cp\u003eAdjusted eigenvalues\u0026thinsp;\u0026gt;\u0026thinsp;0 indicate dimensions to retain. (1 factor retained)\u003c/p\u003e \u003cp\u003eExploratory Factor Analysis (EFA) for a single factor which is both the most common used structure GAD-7 as well as the structure advocated by the Horn's parallel analysis was performed (Kaiser-Meyer-Olkin (KMO) test\u0026thinsp;=\u0026thinsp;0.917, Bartlett\u0026rsquo;s sphericity test, χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;1908.545, df\u0026thinsp;=\u0026thinsp;21, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) using the Unweighted Least Squares (ULS) procedure for factor extraction with 59.6% of the total variance explained (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe confirmatory factor analysis (CFA) testing using the standard maximum likelihood method and the one-factor structure indicated a good model fit, χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;21.207, p\u0026thinsp;=\u0026thinsp;0.096; χ\u003csup\u003e2\u003c/sup\u003e/df\u0026thinsp;=\u0026thinsp;1.51, p\u0026thinsp;=\u0026thinsp;0.218; CFI\u0026thinsp;=\u0026thinsp;0.999; TLI\u0026thinsp;=\u0026thinsp;0.999; RMSEA\u0026thinsp;=\u0026thinsp;0.034, p\u0026thinsp;=\u0026thinsp;0.818; SRMR\u0026thinsp;=\u0026thinsp;0.027 (see Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) where all the cut off points, for a good fit, were adhered. On the other hand, the confirmatory factor analysis (CFA) testing using the robust maximum likelihood method and the one-factor structure indicated an acceptable model fit, χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;53.899, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; χ\u003csup\u003e2\u003c/sup\u003e/df\u0026thinsp;=\u0026thinsp;3.85, p\u0026thinsp;=\u0026thinsp;0.0497; CFI\u0026thinsp;=\u0026thinsp;0.994; TLI\u0026thinsp;=\u0026thinsp;0.991, RMSEA\u0026thinsp;=\u0026thinsp;0.079, p\u0026thinsp;=\u0026thinsp;0.015; SRMR\u0026thinsp;=\u0026thinsp;0.027 (see Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) where the cut off points for CFI, TLI and SRMR suggest a good fit, RMSEA and χ\u003csup\u003e2\u003c/sup\u003e/df suggest an adequate fit, whereas the χ\u003csup\u003e2\u003c/sup\u003e was not adhered.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study is the first to examine the psychometric properties and factor structure of the GAD-7 in a sample of Greek-speaking pregnant and postpartum Cypriot women. The internal consistency of the GAD-7 was high (Cronbach\u0026rsquo;s Alpha\u0026thinsp;=\u0026thinsp;0.907 and MacDonald\u0026rsquo;s Ordinal Omega\u0026thinsp;=\u0026thinsp;0.909), while the correlation between the GAD-7 items ranged from 0.85 to 0.47. Our results indicated no significant differences between pregnant (N\u0026thinsp;=\u0026thinsp;222) and postpartum (N\u0026thinsp;=\u0026thinsp;235) women (p\u0026thinsp;=\u0026thinsp;0.291). Correlations between GAD-7 and overall levels of stress, depression symptoms, and PTSD symptoms were all positive and significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while the participants reporting receiving treatment for mental health concerns at the time of the study had significantly higher (p\u0026thinsp;=\u0026thinsp;0.009) GAD-7 results than the rest of the participants. Horn's parallel analysis supported the extraction of a single factor as optimal. Exploratory Factor Analysis for a single factor was performed with KMO\u0026thinsp;=\u0026thinsp;0.917, Bartlett\u0026rsquo;s sphericity test, χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;1908.545, df\u0026thinsp;=\u0026thinsp;21, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and 59.6% of the total variance explained. Confirmatory factor analysis using the standard ML method indicated a good model fit, χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;21.207, p\u0026thinsp;=\u0026thinsp;0.096; χ\u003csup\u003e2\u003c/sup\u003e/df\u0026thinsp;=\u0026thinsp;1.51, p\u0026thinsp;=\u0026thinsp;0.218; CFI\u0026thinsp;=\u0026thinsp;0.999; TLI\u0026thinsp;=\u0026thinsp;0.999; RMSEA\u0026thinsp;=\u0026thinsp;0.034, p\u0026thinsp;=\u0026thinsp;0.818; SRMR\u0026thinsp;=\u0026thinsp;0.027 whereas confirmatory factor analysis using the robust ML method indicated an acceptable model fit, χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;53.899, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; χ\u003csup\u003e2\u003c/sup\u003e/df\u0026thinsp;=\u0026thinsp;3.85, p\u0026thinsp;=\u0026thinsp;0.0497; CFI\u0026thinsp;=\u0026thinsp;0.994; TLI\u0026thinsp;=\u0026thinsp;0.991, RMSEA\u0026thinsp;=\u0026thinsp;0.079, p\u0026thinsp;=\u0026thinsp;0.015; SRMR\u0026thinsp;=\u0026thinsp;0.027.\u003c/p\u003e \u003cp\u003eOur findings strengthen the evidence for the use of GAD-7 as a brief screening measure for anxiety in the perinatal period [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Another strength of the present study is that the results are based on women who span a spectrum of the perinatal period, namely early pregnancy until 6 months postpartum, unlike other studies which focused only on pregnancy [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] or on even more specific periods, such as the first trimester [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. As NICE\u0026rsquo;s (2014)[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] recommendations for the use of GAD-2 and GAD-7 were mainly based on expert consensus rather than research findings [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], this study fills a gap in the literature, contributing further to the validation of GAD-7 in the perinatal population. It also contributes to the debate in recent literature [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] providing evidence for the usefulness of GAD-7 in screening for anxiety during pregnancy and up to 6 months postpartum.\u003c/p\u003e \u003cp\u003eThe major limitation of this study is the lack of data from other self-report anxiety measures and perhaps more importantly, the lack of data obtained through gold standard methodology, i.e. through well-validated diagnostic structures such as clinical interviews [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The study design did not allow us, therefore, to utilize a cut-off point and maximize the sensitivity and specificity. Nevertheless, the study results provide evidence that GAD-7 can be used as a first screening measure of perinatal anxiety, both for prevention purposes and also for further follow ups including diagnostic interviews and interventions if warranted. It is important to highlight, however, that further validation studies in different socio-cultural contexts are needed if GAD-7 is intended for use in clinical practice with perinatal populations. As a validation study with pregnant women from Ghana and C\u0026ocirc;te d\u0026rsquo;Ivoire [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] suggests, GAD-7 may perform better in higher-income countries.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, the present study indicates that the excellent psychometric properties of GAD-7 for Greek Cypriot pregnant and postpartum women (up to 6 months) constitute GAD-7 an appropriate brief screener for anxiety in the perinatal period. As such, it can be incorporated into standard practice of intrapartum care in Cyprus for the prevention and treatment of anxiety as necessary. These research findings are especially relevant for clinicians and mental health professionals working with women in the perinatal period, and particularly those who are at risk of developing or having pre-existing anxiety symptoms.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study has been approved by the Cyprus National Bioethics Committee (\u0026Epsilon;\u0026Epsilon;\u0026Beta;\u0026Kappa; \u0026Epsilon;\u0026Pi; 2020.01.\u0026Iota;26).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due ethical restrictions but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone of the manuscript authors is in a position of conflict of interest in any respect.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eP.V. conceived and executed the analysis presented in this article. E.M. and S.D. conceived the overall study and took the lead in developing the design. E.H. and A.C. participated in study design and took the lead in executing the study design (recruitment, data collection, study management) in Cyprus. P.V., A.C. and E.H. had the overall responsibility for manuscript planning and preparation. All authors read, edited and approved the final submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis article is based upon work from COST Action CA18138 \u0026quot;Research Innovation and Sustainable Pan-European Network in Peripartum Depression Disorder\u0026quot; (Riseup-PPD), supported by COST (European Cooperation in Science and Technology;https://www.cost.eu/\u003c/p\u003e\n\u003cp\u003eWe would like to thank the women who participated in this study for the generous contribution of their time.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDennis CL, Falah-Hassani K, Shiri R. Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis. The British Journal of Psychiatry. 2017 May;210(5):315-23. https://doi.org/10.1192/bjp.bp.116.187179\u003c/li\u003e\n\u003cli\u003eFawcett EJ, Fairbrother N, Cox ML, White IR, Fawcett JM. 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BJPsych open. 2019 Jan;5(1). https://doi.org/10.1192/bjo.2018.75\u003c/li\u003e\n\u003cli\u003eBarthel D, Barkmann C, Ehrhardt S, Bindt C, International CDS Study Group. Psychometric properties of the 7-item Generalized Anxiety Disorder scale in antepartum women from Ghana and C\u0026ocirc;te d\u0026rsquo;Ivoire. Journal of Affective Disorders. 2014 Dec 1;169:203-11. https://doi.org/10.1016/j.jad.2014.08.004.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"GAD-7, anxiety, perinatal anxiety, pregnancy, postpartum","lastPublishedDoi":"10.21203/rs.3.rs-1551180/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1551180/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAnxiety is increasingly acknowledged as a common mental health issue during the perinatal period. Its prevalence as well as the associated adverse effects constitute screening imperative. This study evaluates the psychometric properties and underlying factor structures of a Greek version of GAD-7 among pregnant and postpartum women (up to 6 months) in Cyprus.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study was conducted from June to December 2020. A total of 457 Cypriot women in the perinatal period (222 pregnant and 235 postpartum) were surveyed. The assessment included anxiety (GAD-7) and depression (EPDS), and psychosocial factors related with anxiety. The internal consistency and factor structure of GAD-7 were evaluated using reliability coefficients, Cronbach\u0026rsquo;s Alpha and McDonald's Omega, and factor analysis, both Exploratory as well as Confirmatory.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eGAD-7 demonstrated good internal consistency (α\u0026thinsp;=\u0026thinsp;0.907; Ω\u0026thinsp;=\u0026thinsp;0.909). Horn's parallel analysis indicated a single factor as the most appropriate. EFA for a single factor gave KMO\u0026thinsp;=\u0026thinsp;0.917 and Bartlett\u0026rsquo;s sphericity test, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001. CFA using the standard ML method indicated a good model fit, χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;21.207, p\u0026thinsp;=\u0026thinsp;0.096; CFI\u0026thinsp;=\u0026thinsp;0.999; SRMR\u0026thinsp;=\u0026thinsp;0.027. More studies are needed to determinate the cut-off point and the maximisation of the scale\u0026rsquo;s sensitivity and specificity in pregnant and postpartum Greek Cypriot women\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eGAD-7 is a valid and reliable measure and healthcare professionals should utilize GAD-7 as a standard instrument for the screening of anxiety symptoms in pregnant and postpartum Greek Cypriot women.\u003c/p\u003e","manuscriptTitle":"Validation of the Generalized Anxiety Disorder Screener (GAD-7) in Cypriot Pregnant and Postpartum Women","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2022-07-26 15:14:07","doi":"10.21203/rs.3.rs-1551180/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-08-26T11:16:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-08-15T06:33:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"63bc925c-d4d7-4c56-850f-7108247429f5","date":"2022-08-15T05:03:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-07-29T10:43:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"3ca3cf25-e433-4aaa-8b9f-825555c24b35","date":"2022-07-28T14:40:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-07-14T21:25:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-07-14T21:22:05+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-07-04T14:53:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-07-04T14:35:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2022-05-09T19:16:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2a0d7271-53b6-4d99-a33f-30da8e4f0a2b","owner":[],"postedDate":"July 26th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2022-10-18T06:14:19+00:00","versionOfRecord":[],"versionCreatedAt":"2022-07-26 15:14:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v2","identity":"rs-1551180","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1551180","identity":"rs-1551180","version":["v2"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}