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Year : 2021  |  Volume : 30  |  Issue : 2  |  Page : 240-248  Table of Contents     

Development and psychometric evaluation of COVID-19 psychological burden scale for Indian health care workers

1 Department of Public Health Dentistry, Government Dental College and Hospital, Vijayawada, Andhra Pradesh, India
2 Department of Oral and Maxillofacial Surgery, SIBAR Institute of Dental Sciences, Takkellapadu, Guntur, India
3 Department of Oral Pathology and Microbiology, SIBAR Institute of Dental Sciences, Takkellapadu, Guntur, India
4 Department of Public Health Dentistry, SIBAR Institute of Dental Sciences, Takkellapadu, Guntur, India
5 Department of Periodontology, SIBAR Institute of Dental Sciences, Takkellapadu, Guntur, India

Date of Submission03-Apr-2021
Date of Acceptance09-Jul-2021
Date of Web Publication24-Sep-2021

Correspondence Address:
Dr. Viswa Chaitanya Chandu
Department of Public Health Dentistry, Government Dental College and Hospital, Vijayawada, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ipj.ipj_71_21

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Background: It is beyond doubt that the health care systems across the globe have been experiencing burdens of unprecedented magnitude in the coronavirus disease (COVID-19) era. However, no psychometric tools were validated in India to assess the impact of COVID-19 on the psychological well-being exclusively among health care workers, given their obvious risk for exposure. Objectives: This study was conducted to develop the first of its kind psychometric tool that measures the psychological burden posed by COVID-19 on Indian health care workers. Materials and Methods: One hundred and sixty-nine health care workers attending COVID-19 duties in four different states of India took part in the study. The initial scale designed was tested for face and content validity. Exploratory factor analysis using direct oblimin rotation with Kaiser normalization was employed to determine the factor structure. Differential item functioning (DIF) analysis with ordinal regression based on the type of COVID-19 facility at which the participant is serving, educational background was done for identification of item bias. Results: COVID-19 Psychological Burden Scale for Indian Health Care Workers (CPBS-IHCW), with 17 items loaded on four components, demonstrated good internal consistency reliability (Cronbach's Alpha 0.873). DIF revealed no item bias based on type of facility and educational background. Significant differences in CPBS-IHCW scores were noted between health care workers serving at different COVID-19 facilities and belonging to different educational backgrounds. Conclusion: CPBS-IHCW is a 17-item, rapidly administrable scale, demonstrating good internal consistency reliability, and temporal stability, which can be used in the assessment of psychological burden among health care professionals catering to the needs of the COVID-19 affected.

Keywords: Health personnel, psychological burnout, psychological stressors, psychometrics, social stigma

How to cite this article:
Chandu VC, Lingamaneni KP, Baddam VR, Pachava S, Marella Y, Bommireddy VS. Development and psychometric evaluation of COVID-19 psychological burden scale for Indian health care workers. Ind Psychiatry J 2021;30:240-8

How to cite this URL:
Chandu VC, Lingamaneni KP, Baddam VR, Pachava S, Marella Y, Bommireddy VS. Development and psychometric evaluation of COVID-19 psychological burden scale for Indian health care workers. Ind Psychiatry J [serial online] 2021 [cited 2022 Jul 1];30:240-8. Available from: https://www.industrialpsychiatry.org/text.asp?2021/30/2/240/326642

The World Health Organization (WHO) declared coronavirus disease (COVID-19) as a pandemic on March 11, 2020.[1] According to the WHO situation report on June 8, 2021, more than 172 million people across the globe tested COVID-19 positive.[2] A huge burden has been placed by COVID-19 on the health care systems across the globe. In this context, health care professionals as front-line workers embraced a multitude of roles at various levels such as community awareness building, laboratory sample collection, monitoring and supervision of suspect cases, and provision of requisite care for the confirmed COVID-19-positive cases. Literature on previous outbreaks underscores the negative impacts of assuming front-line duties on the mental health and psychological well-being of health care workers.[3],[4],[5] It is estimated that the magnitude of anxiety and stress, depression levels, and suicidal inclinations would rise as a consequence of the psychological burden posed by COVID-19.[6] The vulnerability of health care workers in developing psychological symptoms such as insomnia, depression, and anxiety has been discussed in the context of COVID-19.[7],[8] In this fight against the unanticipated COVID-19 pandemic, there are many factors contributing to the appearance of burn-out among health care workers such as working in high-risk areas for infection, availability of suitable personal protective equipment, long work hours to meet the escalating demand, staying away from families, increasing reports on health care professionals communicating the disease, and uncertainty about the future.[7]

Safeguarding the health of health care workers is one of the fundamental responsibilities of any health care system, which includes psychological well-being. The WHO Department of Mental Health and Substance Use developed a series of messages aimed at diverse audiences to reinforce mental health and psychological well-being in these challenging times.[9] In order to provide requisite mental health and psychological support for health care workers in need, it is important to assess the psychological burden among the individuals. Although there are a number of available psychometric scales that measure the impact of COVID-19 on mental health,[10],[11],[12],[13],[14],[15] to the best of our knowledge, there are no validated psychometric measures intended for health care professionals to assess the psychological burden posed by COVID-19 in the Indian context. With this background, the objective of this study was to develop a scale to measure COVID-19 imposed psychological burden among Indian health care workers (IHCW), henceforth referred to as COVID-19 Psychological Burden Scale for IHCW (CPBS-IHCW), and evaluate its psychometric properties.

   Materials And Methods Top

This study was conducted during July and September 2020 among health care professionals attending COVID-19 duties in the Indian states of Andhra Pradesh, Telangana, Madhya Pradesh, and Odisha. Ethical approval for this study was obtained from the Institutional Review Board of Sibar Institute of Dental Sciences (244/Sibar/IEC/2020;17/5/2020). The Government of India has categorized COVID-19 dedicated facilities into three types: COVID Care Center (CCC); Dedicated COVID Health Center (DCHC); Dedicated COVID Hospital (DCH).[16] In addition to these COVID-19 dedicated facilities, field surveillance, field supervision, laboratory sample collection teams were instituted by the health authorities. CCC offers services only for COVID-19 suspect cases having mild and very mild symptoms (fever/upper respiratory tract infection). At DCHC, services for all moderate COVID-19 suspect cases (pneumonia with no signs of severe disease; respiratory rate 15–30 cycles/min; SpO2 90%–94%) shall be offered, whereas DCH is primarily for the provision of comprehensive care to severe COVID-19 suspect cases (respiratory rate ≥30 cycles/min; SpO2 <90% in room air).[16] This classification of patients based on the severity of symptoms can be found in the 'algorithm for isolation of suspect/confirmed cases of COVID-19' proposed by the Ministry of Health and Family Welfare, Government of India.[16] The study sample constituted of a convenience sample of 169 health care professionals, from the disciplines of modern medicine, dentistry, and nursing, who were involved in COVID-19 duties at CCCs, DCHCs, and DCHs during July and September 2020. The administrative heads at the district level were approached to gain access to the eligible participants. The scale was administered to these participants online via their registered contact numbers. All the participants provided informed consent. The background characteristics of age, gender, educational background, and qualification were documented from the study participants. For convenience, the methodology adopted in this study was discussed under the following subheadings: (i) generation of item pool; (ii) assessment of content validity and face validity; (iii) evaluation of corrected item-total correlations (ITC) and internal consistency reliability; (iv) identification of factor structure and scale purification; (v) differential item functioning (DIF) analysis for estimating item bias; (vi) Establishment of the temporal stability of the scale.

  1. Generation of item pool: Thorough review of literature, regarding factors linked with health care professionals' fear of acquiring the disease and the sources of anxiety, preceded the generation of item pool.[7],[17] Independent reviews by the investigators resulted in the drafting of initial questionnaire with 18 items in English. All the items were designed to assess the psychological burden, associated with COVID-19, among health care workers on a four-point (1–4) semantic differential scale, where the estimating facet was clearly mentioned in the choices, with higher scores representing increased psychological burden
  2. The assessment of content validity and face validity: The initial scale with 18 items in English was assessed by a six-member expert panel for content validity that comprised of three psychiatrists and three members from the departments of community medicine. The authors who articulated the initial scale were not a part of the expert panel. The expert panel rated the 18 items on a four-point scale: “quite relevant;” “highly relevant;” “moderately relevant;” “poorly/not relevant.” Seventeen items in the scale were rated to be either “quite relevant” or “highly relevant” by all the panel members, and the item that received “moderately relevant” or “poorly/not relevant” response from few of the panel members was removed from the scale after consensus building. The inter–rater agreement was measured with Intraclass Correlation Coefficient (ICC) (Two-way mixed model, mean of six raters, absolute agreement).[18] The scale level ICC was 0.89 for the 17 item scale, which was pilot tested on 10 health care workers attending COVID-19 laboratory sample collection duties to assess the face validity of the questionnaire. Two items were rephrased after conduct of the debriefing interviews as semantic discrepancy was noted with 3 members, i.e., discrepancy between what the item intends to assess and what the respondents understood from the item
  3. Evaluation of corrected ITC and internal consistency reliability: Corrected ITC to assess the correlation of each of the scale items with the total scale score were used for initial scale purification.[19] Items demonstrating a corrected ITC of <0.3 were intended to be eliminated from the scale, as values below the cut-off indicate limited association of the corresponding item to the overall construct measured by the scale.[20] Internal consistency reliability of the scale was measured using Cronbach's alpha
  4. Identification of factor structure and scale purification: Exploratory factor analysis (EFA) was employed to determine the factor structure. Direct oblimin rotation with Kaiser normalization was done and items with significant cross loadings across components, should there be any, were intended to be removed if the difference between loadings is <0.2[21]
  5. DIF analysis for estimating item bias: DIF was done to check item equivalence.[22] A difference in item responses across different categories of a grouping variable (e.g. COVID-19 health care facility), while controlling for the underlying construct measure is suggestive of DIF. The total score obtained on the scale was considered the conditioning variable and the “interaction term” between the grouping variable and the conditioning variable was also used in DIF analysis to assess the presence of nonuniform DIF. A significant increase in R2 value (>0.02) from model 1, where the conditioning variable was the only covariate, to model 3, where the grouping variable and the “interaction term” were added to model, is suggestive of DIF[22]
  6. Establishment of temporal stability of the scale: Temporal stability of the instrument was evaluated by re-administering the scale to 25 health care workers 1 week after the initial administration. ICC (Two-way mixed effects model, single rater, absolute agreement) was used as a measure for the temporal stability of the scale.

Statistical analysis

SPSS version 20 software (IBM SPSS statistics for windows version 20, Armonk, NY, USA) was used to analyze the data. The following were employed in data analysis: descriptive statistics; EFA using direct oblimin rotation with Kaiser Normalization for determination of factor structure; DIF analysis with ordinal regression based on the type of COVID-19 health care facility the participant serves in and educational background of the participant for identification of item bias; Mann–Whitney test for determining gender variation in CPBS-IHCW scores; Kruskal–Wallis ANOVA, with post hoc Bonferroni-adjusted Mann–Whitney tests for multiple pairwise comparisons, for identifying differences in CPBS-IHCW scores based on the type of COVID-19 health care facility, educational background, and qualification. For DIF analysis, the difference in Nagelkerke R2 values from the three models employed in DIF analysis was used to assess the magnitude of DIF.

   Results Top

Majority of the study participants were females with master's degree in modern medicine. The mean age of the study sample was 28.86 ± 6.38 years. [Table 1] shows the background characteristics of the health care workers who participated in this study. All the 17 items of CPBS-IHCW demonstrated corrected ITC >0.3 (0.31–0.63). [Table 2] presents the corrected ITC and the Cronbach's alpha (if item deleted) values for the 17 item scale. The scale demonstrated good internal consistency reliability (Cronbach's alpha 0.873). Underlying factor structure of the scale was evident from Kaiser Meyer Olkin measure of 0.789. EFA using direct oblimin rotation with Kaiser normalization resulted in a four-component solution (eigenvalue >1). This four-component solution suggested by the “total variance explained” was confirmed by the scree plot [Figure 1]. The four components of CPBS-IHCW were identified as follows, after a series of consensus-building based on the content of items loaded on these components: “Personal vulnerability” (items 1, 3, 7, 8, 9); “workplace preparedness and safety” (items 10, 11, 12, 16, 17); “fear of societal prejudice and discrimination” (items 5, 6, 13, 14); “family well-being” (items 2, 4, 15). The maximum possible score for CPBS-IHCW is 68, while the minimum score is 17. The component loadings, communalities, and the total variance explained by the factors in EFA are presented in [Table 3]. The four sub-scales of CPBS-IHCW accounted for slightly more than 73% of total variance. Item level DIF analysis, done with ordinal regression, showed item bias for Item 11 with COVID-19 health care facility as the grouping variable [Table 4]. However, the magnitude of DIF was small (0.052). There were significant differences in CPBS-IHCW scores between participants serving at different COVID-19 health care facilities, with those participants from DCH demonstrating higher psychological burden scores compared to those serving in other types of facilities. This difference was also noted based on educational background, as the CPBS-IHCW scores of nurses were significantly higher than the participants from modern medicine and dentistry [Table 5]. An ICC (Two-way mixed effects model, single rater, absolute agreement) of 0.93 between test and re-test among 25 health care workers confirmed temporal stability of the instrument.
Table 1: Background characteristics of the study population (n=169)

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Table 2: Item level descriptive statistics, item-total correlation, and internal consistency reliability estimates

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Figure 1: Scree plot

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Table 3: Pattern matrix from exploratory factor analysis showing the component loadings and communalities for the seventeen items of the CPBS-IHCW

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Table 4: Differential item functioning analysis with ordinal regression

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Table 5: Differences in CPBS-IHCW scores based on the background characteristics

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   Discussion Top

It is undeniable that the world would not be able to finish this COVID-19 marathon without the services of health care workers on the front line. In this process, the health care workers are exposed to numerous uncertainties, fears, and stressors. The aftermath of any epidemic would include psychological distress and social stigma.[7],[8] The world has experienced these psychological consequences previously during the time of influenza,[23] SARS outbreak,[24],[25] and with the gradually evolved AIDS epidemic.[26] Shanafelt et al. summarized the possible sources of fear and anxiety among health care workers during the COVID-19 pandemic; they have also discussed the conventional self-reliant nature of health fraternity as an important contributor to anxiety while dealing with a previously un-encountered disease which is outside the professionals' area of clinical expertise.[8] A validated scale to assess the psychological burden among health care professionals offering COVID-19 services goes a long way in supporting these professionals from the mental health and psychological end. In light of lack of psychometric tools to assess COVID-19 imposed psychological burden among health care workers, CPBS-IHCW offers a rapidly administrable and valid solution. To the best of our knowledge, this is the first COVID-19 psychometric instrument developed to assess the psychological burden among Indian health care professionals.

CPBS-IHCW showed good internal consistency reliability with Cronbach's alpha of 0.87, well above the cut-off suggested in literature.[27] It is a rapidly administrable 17–item tool, using a semantic differential scale, which was considered over Likert scale to eliminate the potential acquiescence bias.[28] The evaluative dimension is explicitly stated on a semantic differential scale rather than asking the subject to respond in affirmative or negative to a directive statement. EFA produced a four-factor solution reflecting the multidimensional structure of CPBS-IHCW. The correlation matrix between CPBS-IHCW and its four subscales confirmed that all the subscales are specific with regard to the measurement of the underlying construct of psychological burden; with moderate inter-sub scale correlation coefficients. The negative component loadings for items in “work place preparedness and safety” component were because the items were phrased in a reverse manner, that strong disagreement to these items increases the CPBS-IHCW scores, while it is the opposite for items loaded on the other three components. DIF analysis confirmed that there is no item bias in CPBS-IHCW, with no differences in item responses based on the type of COVID-19 health care facility and educational background, except for Item 11, the magnitude of DIF for which, however, is very small. As DIF assumes unidimensionality, DIF analysis was done separately for items loaded on the individual factors.[29] It was identified that the health care workers serving in DCH had higher CPBS-IHCW scores which could be due to the more comprehensive and demanding nature of medical care provision for severe COVID-19 cases. This finding could be understood as provisional evidence for the construct validity of CPBS-IHCW. Nurses demonstrated higher CPBS-IHCW scores compared to health professionals from modern medicine and dentistry, the rationale for which, in the Indian context, could be the discrepancy between the level of information nurses have with regard to COVID-19 and the nature of duties they assume which demand closely working with infected persons. A study by Tan et al. among health care workers in Singapore in relation to the psychological impact posed by COVID-19 reported anxiety among 14.5% and depression among 8.9% of the study sample.[30] In the present study, no attempt was made to categorize participants based on CPBS-IHCW. Though there is limited consensus available on the recommended sample size for EFA, larger samples are conventionally advised. The sample size considered in this study is in accordance with the recommended subjects to item ratio of 30:1 in EFA.[31] Smaller subject to item ratios of 6:1 were recommended and used in psychometric research.[32],[33] It is also noteworthy that psychological aspects are hugely culture-specific and no single instrument can be universally valid. Culture-specific, contextual instruments tested for psychometric properties are the need of the hour owing to immense variations in the work environments, cultural differences, health-related attitudes, and beliefs between health care workers from different countries across the globe. The results of this study need to be assimilated in light of the convenience sampling technique adopted in this study and the unequal gender distribution in the study sample.

   Conclusion Top

Based on the results of this study, we conclude that CPBS-IHCW is a valid and reliable measure to evaluate psychological burden among health care workers operating at various levels, which is of great value in the assessment of psychological burden among health care professionals catering to the needs of the COVID-19 affected.


The authors sincerely acknowledge the contributions made by all the participating health care workers in this study to comprehensively understand the scenario and develop this instrument.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

COVID-19 Psychological Burden Scale for Indian Health Care Workers (CPBS-IHCW)

How afraid are you of acquiring COVID-19 at work?

1. Extremely afraid ◯ ◯ ◯ ◯ Not at all afraid

2. How afraid are you that your family members may acquire COVID-19 because of you?

Extremely afraid ◯ ◯ ◯ ◯ Not at all afraid

3. How frequently are you feeling that you have acquired COVID-19?

Almost always ◯ ◯ ◯ ◯ Never

4. How concerned you are about the possibility of you propagating COVID-19 to your colleagues at workplace?

Extremely concerned ◯ ◯ ◯ ◯ Not at all concerned

5. How afraid are you that you and your family may experience discrimination from society as you are involved in COVID-19 duties?

Extremely afraid ◯ ◯ ◯ ◯ Not at all afraid

6. How anxious are you about the perceptions of the community during the isolation/self-quarantine period you will have to undergo after getting relieved from COVID-19 duties?

Extremely anxious ◯ ◯ ◯ ◯ Not at all anxious

7. How concerned are you that your involvement in COVID-19 related work may negatively affect your future professional duties?

Extremely concerned ◯ ◯ ◯ ◯ Not at all concerned

8. How frequently is your sleep getting affected because of thoughts relating to COVID-19?

Almost always ◯ ◯ ◯ ◯ Never

9. How afraid are you of dying from COVID-19?

Extremely afraid ◯ ◯ ◯ ◯ Not at all afraid

10. How satisfied are you with the training received in preparation for COVID-19 duties?

Extremely satisfied ◯ ◯ ◯ ◯ Not at all satisfied

11. How confident are you in fulfilling the COVID-19 related responsibilities delegated to you?

Extremely confident ◯ ◯ ◯ ◯ Not at all confident

12. How assured are you about the quality and comprehensiveness of COVID-19 related evidence that you have received?

Very much assured ◯ ◯ ◯ ◯ Not at all assured

13. How frequently have you been thinking of not attending COVID-19 duties delegated to you because of pressure from family members or close acquaintances?

Almost always ◯ ◯ ◯ ◯ Never

14. How assured are you about receiving necessary support from the community in case you develop COVID-19 related symptoms?

Very much assured ◯ ◯ ◯ ◯ Not at all assured

15. How worried are you about the wellbeing of your family when you are fulfilling the delegated COVID-19 responsibilities?

Extremely worried ◯ ◯ ◯ ◯ Not at all worried

16. How apprehensive are you that the family members of an infected person may resort to violence against you or the facility in which you serve?

Extremely apprehensive ◯ ◯ ◯ ◯ Not at all apprehensive

17. How satisfied are you with the current access you have to personal protective equipment?

Extremely satisfied ◯ ◯ ◯ ◯ Not at all satisfied

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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