Development and validation of the COVID-19 Anxiety Scale for Japanese elite athletes
Abstract
Abstract:Introduction: Japanese elite athletes were affected by the spread of COVID-19 infection. Four years after the pandemic, COVID-19 is still spreading and subsiding, and it is expected that some athletes are still concerned about COVID-19. Therefore, we developed the COVID-19 Anxiety Scale for Elite Athletes (CAS-EA) to measure COVID-19 anxiety among Japanese elite athletes and to examine its reliability and validity. Method: This is an observational cross-sectional study. In study 1, a 35-item anxiety questionnaire about COVID-19 was administered to 100 elite athletes on 8/18-9/1/2020. In study 2, 296 elite athletes were asked to respond to the CAS-EA, the Japanese version of State-Trait Anxiety Inventory (STAI), and the Japanese version of the Fear of Coronavirus Virus Scale (FCV-19S) from 8/31-11/8/2022. Results: In study 1, an exploratory factor analysis was conducted to create CAS-EA, which consisted of 19 items with four factors: Restrictions, Sport, Practice and Athlete value. The reliability of the scales was examined, confirming a certain internal consistency. In addition, study 2 showed significant positive correlations with CAS-EA and related scales. In the COVID-19 disaster, psychological stress was more strongly associated with A-trait than physical stress, a result that could be explained by Spielberger’s Trait-state anxiety theory. Furthermore, CAS-EA scores were significantly higher for female than for male, which was consistent with the results of previous studies. Conclusion: An attempt was made to create a scale to measure anxiety about COVID-19 in Japanese elite athletes, and a 4-factor, 19-item CAS-EA was created. The reliability and validity of the scale were tested and confirmed successfully.
Introduction
Coronavirus disease 2019 (COVID-19) greatly affected the daily lives and mental health of people around the world [1]. A survey conducted by the Japanese Olympic Committee (JOC) of designated athletes at the time of the COVID-19 emergency declaration revealed that many athletes had some restrictions on their training. In addition, more than 20% of summer athletes experienced psychological distress [2]. Furthermore, we know that strong restrictions on interpersonal contact due to infection prevention measures had a significant impact on athletes, forcing some athletes to reconsider the value of athletes in society itself [3]. These previous studies indicated that Japanese elite athletes were affected by the spread of COVID-19 infection.
Although restrictions have been eased, COVID-19 still affects athletes’ mental health. Tamm et al. report that more than a year after the COVID-19 pandemic, despite the fact that the competitive environment has recovered, anxiety about the future is causing high levels of distress for many elite athletes [4]. Ehara et al. found that athletes are anxious about contact with others during practice and on the practice field, even during the restriction relaxation phase [5]. COVID-19 continues to expand and converge, and there is no way to predict when a more infectious variant will emerge and restrict competition again. Some athletes are expected to be concerned about COVID-19 because they are in environments where the infection can easily spread, such as on tours or in group activities.
Several psychometric measures of COVID-19 (in the general population) have been reported [6], including the Fear of Coronavirus-19 Scale [7], a measure of COVID-19 fear, which has been validated by Midorikawa et al. [8] and is widely used clinically. On the other hand, no reports of anxiety scales for elite Japanese athletes, who are often placed in rather special situations. Thus, we aimed to create a scale (COVID-19 Anxiety Scale for Elite Athletes; CAS-EA) for measuring COVID-19-related anxiety in Japanese elite athletes. We conducted the first survey during the difficult period of athlete activity in the early stages of the COVID-19 infection spread, when our priority was to understand the actual status of COVID-19 anxiety among elite athletes in Japan, and we were unable to examine even the validity of the scale. Therefore, a second study was conducted to examine the reliability and validity of the CAS-EA. These were Study 1 and 2, which examined the validity of the CAS-EA as a measure of anxiety related to the COVID-19 in Japanese elite athletes. These findings may assist athletes in COVID-19 disasters. In addition, these findings may be useful in the case of other infectious disease outbreaks, as athletes are in environments where infectious diseases are more likely to spread.
Methods
Study 1: Creation of the scale
Ethical considerations
Participants were informed about the purpose of the study and gave written consent. Participants completed questionnaires during visits to the High Performance Sport Center (HPSC) sports clinic for sports injuries, poor physical conditions, menstrual abnormalities, skin conditions, dental care. The HPSC sports clinic is a clinic attached to the National Training Center that is available only to athletes who are national team level Athletes. This study was conducted with the approval of the Ethical Review Committee of the Japan Institute of Sports Sciences (Approval No. 2020-018).
Survey participants and survey period
This study is an observational cross-sectional study. The study population consisted of 100 national-level athletes (51 males, 48 females, and 1 no answer) who visited the HPSC sports clinic between August 18 and September 1, 2020, and agreed to participate in the study.
Survey content
Suzuki et al. [3] conducted an open-ended survey of 55 national team level athletes to determine what concerns Japanese elite athletes have during the COVID-19 pandemic. Responses to the question “Please feel free to describe your concerns about COVID-19” were analyzed by three sport psychological staff members and one author, a nurse, using the KJ method by Kawakita (1967), which revealed that there were 16 anxiety factors (Table 1). Items that were thought to be representative of each of these 16 anxiety factors were selected by the same four analysts from the free-answer questions in the aforementioned previous study, making a total of 35 items in the questionnaire (see Electronic Supplementary Material, ESM 1). For each item, participants were asked to respond using a five-point scale.
Statistical analysis
For the item analysis, the mean and standard deviation of the 35 CAS-EA draft items were calculated, and items with ceiling or floor effects were checked to see, and those that were excluded from the subsequent analysis. Then, after testing the normality of the remaining items, Pearson’s correlation coefficients between each item to see overlapping content excluded from further analysis.
For the remaining items, an exploratory factor analysis using the main factor method and Promax rotation was conducted to construct the factor structure. The number of factors was determined based on the fact that these were composed of items with factor loadings of 0.4 greater and on interpretability. SPSS ver. 24.0 for Windows was used for the above analyses.
Study 2: Examination of validity
Ethical considerations
The same procedures were followed as in Study 1. This study was conducted with the approval of the Ethical Review Committee of the Japan Institute of Sports Sciences (Approval No.2022-029).
Study participants and study period
Our subjects were 296 national team level athletes who visited the HPSC Sports Clinic for the same purpose as Study 1, and so on from August 31 to November 8, 2022 and provided consent to participate in this study.
Survey content
COVID-19 Anxiety Scale for Elite Athletes (CAS-EA)
Using the scale developed in Study 1, the participants were asked to respond on a 5-point scale. Additionally, at the time of Study 2, the Tokyo Olympic and Paralympic Games had concluded. Consequently, the author (nurse) who formulated the CAS-EA, and three sports psychology specialists collaborated to review the questionnaire. They collectively decided to modify the statement “I am anxious about not being able to participate in the Tokyo Olympic and Paralympic Games” to “I am anxious that I won’t be able to participate in a tournament that I had set my sights on.”
Japanese version of the State-Trait Anxiety Inventory (STAI) [9]
This scale is a Japanese adaptation of the STAI (Spielberger et al., 1970) and comprises two components: the state anxiety scale (A-State), reflecting the intensity of anxiety at the time of assessment, and the trait anxiety scale (A-Trait), indicating a predisposition to anxiety as a personality trait. Both scales share a common structure with 20 questions and four-point ratings (ranging from 1 to 4 points) [9].
Japanese version of the Fear of Coronavirus-19 Scale (FCV-19S) [10]
This is the Japanese version of the FCV-19S [8], a scale that measures fear of COVID-19, a problem unique to the COVID-19 crisis. The scale consists of seven questions, and respondents provide answers on a five-point scale [7]. Midorikawa et al. hold that a total score of 21 points or more is an appropriate cutoff value for identifying people whose fear of COVID-19 is disrupting their daily life [10].
Statistical analysis
The reliability of the factor-analyzed scales was evaluated by calculating Cronbach’s alpha coefficients. Then for the examination of criterion linkage validity, Spearman’s correlation coefficients between FCV-19S, STAI, and CAS-EA were calculated after confirming the normality of the population. We expected CAS-EA scores to be positively correlated with these scales. In addition, since the high FCV-19S group was predicted to have significantly higher CAS-EA scores than the low group, after testing for normality, Mann-Whitney’s U test was used to confirm the difference in CAS-EA scores between the two groups. Criterion linkage validity was examined based on these results.
Spielberger, in his Trait-state anxiety theory, showed that individuals with high A-trait feel more threatened in psychological stress, where personal validity is assessed, than in physical stress [11]. Because the results of Study 1 allowed us to interpret the CAS-EA subfactors as physical stress and psychological stress, we predicted that the A characteristic would be more strongly associated with psychological stress, and we tested this using Spearman’s correlation. In addition Mann-Whitney’s U test was used to confirm differences in CAS-EA scores by sex and sports type, and results were compared with those of previous studies to examine construct validity. The aforementioned analyses were conducted using SPSS version 24.0 for Windows.
Results
Study 1: Creation of the scale
Breakdown of study participants
Participants’ ages ranged from 20-44 (overall: 25.96 ± 4.91; males: 25.48 ± 4.39, females: 26.47 ± 5.42). The response rate was 100% and all data were subjected to statistical analysis.
Item analysis and exploratory factor analysis
For the 35 items listed in the draft version of CAS-EA, 6 items with mean (M) ± standard deviation (SD) less than 1 or more than 5 were deleted. Furthermore, two items that were determined to have high correlation coefficients and significant overlap were removed.
An exploratory factor analysis using the main factor method with promax rotation was conducted on the 27 items remaining after the item analysis. A four-factor structure was assumed based on the decay rate of eigenvalues and interpretability, and the main factor method and promax rotation were used. As a result, 8 items that did not show sufficient factor loadings (≤.400) were excluded. The first factor was named “Restrictions” because it consisted of items detailing concerns about restrictions during the COVID-19 crisis. The second factor was named “Sport,” comprised of items related to anxiety about the sport itself, including motivation and competitive ability. The third factor was named “Practice,” comprised of elements related to anxiety specific to practice, even within competitions. The fourth factor was named “Athlete value,” comprised of concerns about changes in the nature of sport and the value of athletes amidst the COVID-19 crisis. The CAS-EA was created in accordance with these four factors, consisting of 19 items in total. Cronbach’s alpha coefficients for the CAS-EA and each subfactors are shown in Table 2.
Study 2: Examination of validity
Breakdown of study participants
Participants ranged in age from 16 to 48 years (overall: 24.29 ± 5.23 years; male: 24.47 ± 4.87 years; female: 24.09 ± 5.61 years). The breakdown of sport types was 264 for individual sport athletes and 32 for team sport athletes. The response rate was 100%, but because there was one missing value in the response to the FCV-19S among the 296 participants, 295 participants were used in the analysis using the FCV-19S.
Examination of reliability and validity
We calculated Cronbach’s alpha coefficient for CAS-EA and obtained a value of .918. In addition, we calculated Cronbach’s alpha coefficient for each subscale. “Factor 1: Restrictions” had α = .868, “Factor 2: Sport” had α = .758, “Factor 3: Practice” had α = .790, and “Factor 4: Athlete value” had α = .767. Overall, a certain degree of internal consistency was confirmed.
The correlation coefficient results between the CAS-EA and related scales, are reported in Table 3. Significant positive correlations were found between the CAS-EA and related scales. In addition, a Mann-Whitney U test was executed with the CAS-EA serving as the dependent variable and the FCV-19S (categorized by cutoff value) as the independent variable. The findings (Table 4) revealed that athletes surpassing the FCV-19S cutoff exhibited significantly higher CAS-EA.
Table 3 shows the results of the correlation coefficients between each subfactor of the CAS-EA and STAI. The correlation coefficients with STAI were higher for the “Sport” and “Athlete value” than for the “Restrictions” and “Practice”. In particular, the correlation coefficients between the A-Trait and the “Restrictions” and “Athlete value” were positive at .40 or higher.
In addition, Table 5 shows CAS-EA scores by sex and sports type. Females scored significantly higher on the total scale, “Sport” and “Restrictions” compared to males, and athletes in individual sports scored higher only on “Practice” compared to athletes in team sports.
Discussion
Exploratory factor analysis and reliability of CAS-EA
Previous studies have reported isolation, training interruption, loss of income, and career as anxiety factors during the COVID-19 pandemic [12]. Furthermore, they reported that the main sources of anxiety at more than one year after release from confinement were related to the future of the sport and their sports careers [13]. Similar anxiety factors to these previous studies were extracted from the results of this study. Although the CAS-EA was created immediately after COVID-19 pandemic, the high degree of internal consistency still observed two years later ensured the reliability of the CAS-EA. While overall anxiety scores were not high, athletes with high COVID-19 fear had significantly higher CAS-EA scores than the other players (Table 4). The results showed that even after COVID-19, some athletes had concerns about “Restrictions” “Sport” “Practice” and “Athlete value”. It was suggested that even post-COVID-19, we need to continue to monitor the progress carefully, keeping in mind that some athletes have concerns about COVID-19.
Review of the validity of CAS-EA
Examination of criterion linkage validity
FCV-19S showed a moderate correlation with CAS-EA total score and a weak to moderate correlation with CAS-EA subfactors. STAI showed moderate correlation with CAS-EA total score and weak to moderate correlation with CAS-EA subfactors. These results were in line with the hypothesis that the CAS-EA would be positively correlated with the related measures. Furthermore, athletes who exceeded the FCV-19S cutoff had significantly higher CAS-EA, as expected, indicating that athletes with higher COVID-19 fears had significantly higher CAS-EA scores. The positive correlations with related scales ensured the criterion linkage validity of the CAS-EA.
Examination of construct validity
Spielberger’s theory indicated that people with higher A-trait felt more threatened in psychological stress, where personal validity is assessed, than in physical stress [11]. The “Sport” and “Athlete value” of the CAS-EA are related to motivation as an athlete, relationships with others, and evaluation by others. As such, they are similar to psychological stress, in which an individual’s aptitude is evaluated. On the other hand, the “Restrictions” and “Practice” relate to the restrictions of COVID-19 disasters and are similar to physical stress. Therefore, “Sport” and “Athlete value” may have correlated more strongly with A-Trait (Table 3) than other factors. Furthermore, the Japan specific background of the COVID-19 pandemic was the declaration of a state of emergency without mandatory lockdown. As a result, the Japanese government urged its citizens to avoid unnecessary outings, limit contact with others, and adopt a policy of social distancing [14]. However, since the declaration of a state of emergency was a request and not a mandate, it depended primarily on the Japanese people’s awareness and self-control [15]. This required the Japanese to demand strict ethical standards for themselves and others. Uricher et al. [16] conducted a cross-cultural study to determine whether cultural background was related to people’s behavior during COVID-19 pandemic. They reported that Japanese participants demanded higher levels of infection prevention behavior from themselves and those around them and imposed stricter ethical standards than US participants. Thus, the synergistic effect of Spielberger’s theory and Japan-specific background in which the response to the COVID-19 pandemic depended on the self-control of each individual citizen may have resulted in a stronger relationship between psychological stress and A-Trait than physical stress. COVID-19 has been expanding and converging, and there is no telling when the next outbreak will occur. During the period of COVID-19 infection spread, Japanese athletes may be particularly demanding of themselves and those around them in terms of strict ethical standards. These results indicated that athletes with anxious temperaments are at higher risk for psychological stress (such as being evaluated for correctness).
In addition, several previous studies have shown that female is more anxious than male in the COVID-19 disaster [17], and our study showed similar results (Table 5). On the other hand, when CAS-EA scores were compared sports type, significant differences were found only for the “Practice”, but not for the total score. There are no consistent results regarding comparisons sports type. Fiorilli et al. found that athletes in individual sports have higher psychological stress than athletes in team sports [18], while Batalla-Gavalda et al. reported that team sport athletes had greater overall mood disorders, nervousness, and depression than individual sport athletes [19]. In addition, Rubio et al. reported that team athletes adapted to COVID-19 disasters more quickly than individual sport athletes [20]. The results of this previous study may explain the higher scores on the “Practice” for individual sport athletes in present study. However given the overwhelmingly small number of team sport athletes in this study, the number of subjects needs to be increased and a re-examination conducted.
As described above, the findings of this study do not contradict Spielberger’s Trait-state anxiety theory and previous studies on sex differences. Therefore, we argue that these findings contribute to confirming the criterion linkage validity and construct validity of the CAS-EA. The results of this study showed that some athletes had COVID-19 anxiety even after COVID-19, suggesting high-risk factors such as anxious temperament and female. Support staff needs to keep this in mind when providing support.
Limitations
The most important thing to emphasize is that team sport athletes are much less likely than individual sport athletes. A study conducted by Melnyk et al. reported that individual sport athletes had less social well-being compared to team sport athletes, and them sport athletes had less psychological well-being compared to individual sport athletes [21]. Since the anxiety factors and anxiety intensity may differ depending on the sports type, it is necessary to continue the survey by increasing the sample of team sport athletes in the future.
Conclusion
This study was conducted to develop a scale to measure anxiety about COVID-19 among Japanese elite athletes and to examine its validity and reliability. Scale items were refined in Study 1, and reliability and validity were examined in Study 2. Based on these results, the CAS-EA ensured a certain degree of reliability and validity as a scale to measure Japanese elite athletes’ anxiety tendency regarding the COVID-19. We hope that the results of this study will help athletes cope with their anxiety when unprecedented life events stand in the way of their careers.
Electronic Supplementary Materials
The following electronic supplementary material is available with this article at https://doi.org/10.1024/2674-0052/a000080
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