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Validation of the Hamilton Anxiety Rating Scale and State Trait Anxiety Inventory A and B in Arabic among the Lebanese population

Published:March 29, 2020DOI:https://doi.org/10.1016/j.cegh.2020.03.028

      Abstract

      Objectives

      Our aim in this study was to translate the Hamilton Anxiety Rating Scale (HAM-A), State Trait Anxiety Inventory (STAI-A and B) scales to Arabic, linguistically validate them for use in a representative sample of the Lebanese population, and to check the reliability of these Arabic versions.

      Methods

      This study is cross-sectional, conducted between November 2017 and March 2018, which enrolled 1332 community dwelling participants using a proportionate random sample from all Lebanese Mohafazat.

      Results

      Three factor analyses for the anxiety scales were run over the whole sample (N = 1332). All of the HAM-A, STAI-A and STAI-B items could be extracted from the list. All items from all the scales did not over-correlate to each other (r > 0.9), did not have a low loading on factors (<0.3) or a low communality (<0.3). The factor analysis results showed 2 factors for HAM-A (Cronbach alpha = 0.921), 3 factors for STAI-A (Cronbach alpha = 0.928) and STAI-B (Cronbach alpha = 0.898). A significantly high ICC was found between the HAM-A, STAI-A (ICC = 0.709) and STAI-B (0.704). In addition, a significantly high ICC was found between the STAI-A and B scales (ICC = 0.884).

      Conclusion

      The linguistically validated Arabic versions of these scales can be used to screen for anxiety among the Lebanese populations.

      Keywords

      1. Introduction

      Anxiety is as a transitory emotional state affected by individual personality traits that varies across culture and situations.
      • Spielberger C.D.
      Anxiety as an emotional state.
      The intensity of anxiety varies over time and differs from person to other according to stressful life events, situations and cultural background.
      • Ollendick Thomas
      • King Neville
      • Yule William
      International Handbook of Phobic and Anxiety Disorders in Children and Adolescents.
      It is considered as a universal pheromone that can be presents across cultures.
      The severity of anxiety symptoms could be measured by using different psychometric tools such as the state-trait anxiety inventory (STAI) and the Hamilton Anxiety Rating Scale (HAM-A). These scales are widely and extensively used in research and clinical studies and are available in different versions for adults and children.
      • Julian L.J.
      Measures of anxiety: state‐trait anxiety inventory (STAI), beck anxiety inventory (BAI), and hospital anxiety and depression scale‐anxiety (HADS‐A).
      • Spielberger C.D.
      Assessment of state and trait anxiety: conceptual and methodological issues.
      • Spielberger C.D.
      State-Trait Anxiety Inventory: Bibliography.
      • Spielberger C.D.
      • Gorsuch R.L.
      • Lushene R.
      • Vagg P.R.
      • Jacobs G.A.
      Manual for the State-Trait Anxiety Inventory.
      The STAI has been validated and translated to several languages and is considered as a standard international tool for measuring anxiety in research.
      • Spielberger C.D.
      State-Trait Anxiety Inventory: Bibliography.
      A validated Arabic version of the STAI, with an adequate internal consistency reliability, exists among patients attending dental clinics.
      • Bahammam M.A.
      Validity and reliability of an Arabic version of the state-trait anxiety inventory in a Saudi dental setting.
      Also, the HAM-A has been proven to have a high reliability and sensitivity for measuring anxiety and has been validated among adults and adolescents as well.
      • Clark D.B.
      • Donovan J.E.
      Reliability and validity of the Hamilton anxiety rating scale in an adolescent sample.
      ,
      • Maier W.
      • Buller R.
      • Philipp M.
      • Heuser I.
      The Hamilton Anxiety Scale: reliability, validity and sensitivity to change in anxiety and depressive disorders.
      More specifically, the Hamilton Anxiety Rating Scale (HAM-A) is a psychological questionnaire used by clinicians to rate the severity of a patient's anxiety. Anxiety can denote things such as “a mental state … a drive … a response to a particular situation … a personality trait … and a psychiatric disorder".
      • McDowell I.
      Measuring Health: A Guide to Rating Scales and Questionnaires.
      Nonetheless it was one of the first anxiety rating scales to be published, the HAM-A remains widely used by clinicians.
      • Maier W.
      • Buller R.
      • Philipp M.
      • Heuser I.
      The Hamilton Anxiety Scale: reliability, validity and sensitivity to change in anxiety and depressive disorders.
      It was originally published by Max Hamilton in 1959. For clinical purposes, only severe or inadequate anxiety is attended to. This scale is considered a “clinical rating” of the range of anxiety, and is proposed for individuals that are “already diagnosed with anxiety neurosis".
      • Hamilton M.
      The assessment of anxiety states by rating.
      As for the State-Trait Anxiety Inventory (STAI), it measures two types of anxiety – state anxiety, or anxiety about an event, and trait anxiety, or anxiety level as a personal characteristic; and used in diagnoses, in both clinical and other medical settings.
      • Spielberger C.D.
      • Gorsuch R.L.
      • Lushene R.
      • Vagg P.R.
      • Jacobs G.A.
      Manual for the State-Trait Anxiety Inventory.
      The advantage of this scale is that could be applied towards assessing different types of anxiety. This was a new development because all other questionnaires focused on one type of anxiety at the time.
      • Tilton S.
      Review of the state-trait anxiety inventory (STAI).
      Appropriate, validated and translated scales are needed to explain and predict anxiety in each country due to the influence of linguistic and cultural differences. The use of the validated scale in different languages, to assess the severity of the anxiety symptoms, demands two concepts: (1) maintaining a level of psychometric properties comparable to the original version and (2) adapting the scale to the cultural of the country. The validated and translated scale with a good reliability, will be helpful in clinical settings and research.
      • Hofmann S.G.
      • Hinton D.E.
      Cross-cultural aspects of anxiety disorders.
      Therefore, it is essential to validate the Arabic version of the STAI and HAM-A scales for cultural adaptation among the Lebanese population in order to measure the severity of anxiety. Our aim in this study was to translate the HAM-A, STAI-A and B scales to Arabic, linguistically validate them for use in a representative sample of the Lebanese population, and check the reliability of these Arabic versions.

      2. Methods

      2.1 Study design and sampling (sample 1)

      This study is cross-sectional, conducted between November 2017 and March 2018, which enrolled 1332 community dwelling participants using a proportionate random sample from all Lebanese Mohafazat (Beirut, Mount Lebanon, North, South and Bekaa). Each Mohafaza is divided into Caza (stratum), two villages were randomly selected from the list of villages provided by the Central Agency of Statistics in Lebanon. Patients were randomly selected from each village. All participants above 18 years of age were eligible to participate. Excluded where the patients with psychotic problems, mental retardation, dementia or who refused to fill the questionnaire. Data collection was performed through personal interviews with participants by trained, study independent personnel.

      2.2 Ethical approval

      The Psychiatric Hospital of the Cross Ethics and Research Committee, in compliance with the Hospital's Regulatory Research Protocol, approved this study protocol (HPC-009-2018) based on the fact that the autonomy and confidentiality of participants were respected and since it was an observational study, no harm will be prompted to them. The purpose and requirement of the study was informed to each patients. Consent was obtained as written approval on the ethical consent form.

      2.3 Minimal sample size calculation

      Comrey and Lee suggested that a minimum of 10 observations per variable is necessary in order to avoid computational difficulties.
      • Comrey A.L.
      • Lee H.B.
      A First Course in Factor Analysis.
      Since the STAI-A and B scales questionnaire contains 40 questions (20 questions for each scale), a minimal sample of 400 patients was needed to conduct an exploratory factor analysis.

      2.4 Questionnaire

      The questionnaire used during the interviewed was in Arabic, the native language of Lebanon. A trained staff was in charge of collecting the data, via a personal interview with each participant. This person was independent of this study. The first part assessed the sociodemographic characteristics of the included population (age, gender, educational level of the patient and his parents, marital status, socioeconomic level, alcohol consumption, family history of psychiatric diseases). The socioeconomic level, defined as the family monthly income, was divided into 3 categories: low (<1000 USD, intermediate (1000–2000 USD) and high (2000 USD). Also, we asked the patient if he got a physician diagnosis of anxiety and was taking a medication to treat it. The other parts comprised the different scales used in this study as follows:

      2.5 Hamilton anxiety scale (HAM-A)

      The HAM-A
      • Hamilton M.
      The assessment of anxiety states by rating.
      entails 14 items, each categorized by a series of symptoms, and measures mental agitation and psychological distress, as well as anxiety-related physical complaints. The responses on the scale were measured on a 5-point Likert scale: 0 (symptoms not present), 1 (mild symptoms), 2 (moderate symptoms), 3 (severe symptoms) and 4 (very severe symptoms). The total score was calculated by summation of the 14 items.

      2.6 State-trait anxiety inventory (STAI) A and B

      It is composed of 40 questions that measure two types of anxiety - state anxiety, or anxiety about an event (STAI-A), and trait anxiety, or anxiety level as a personal characteristic (STAI-B). The answers follow a 4-point Likert scale, with 1 (not at all), 2 (somewhat), 3 (moderately so) and 4 (very much so) for STAI-A and 1 (almost never), 2 (sometimes), 3 (often) and 4 (almost always) for STAI-B. Higher scores are positively correlated with higher levels of anxiety.
      • Spielberger C.D.
      • Sydeman S.J.
      State-trait anxiety inventory and state-trait anger expression inventory.
      A permission was obtained from Mind Garden Inc. to use the STAI A and B scales in this study.

      2.7 Forward translation into Arabic

      A single bilingual translator, Arabic native fluent in English, aware of the concepts of the three anxiety scales translated the English versions of the scales into Arabic. An expert committee, composed of health care professionals (psychiatrists and psychologists), a language professional and the original translator, had reviewed and revised the translated questionnaire in order to check for idiomatic and conceptual equivalence of the Arabic translated version.
      • Beaton D.E.
      • Bombardier C.
      • Guillemin F.
      • Ferraz M.B.
      Guidelines for the process of cross-cultural adaptation of self-report measures.
      • Beaton D.
      • Bombardier C.
      • Guillemin F.
      • Ferraz M.B.
      Recommendations for the Cross-Cultural Adaptation of Health Status Measures.
      • Al-Bannay H.
      • Jarus T.
      • Jongbloed L.
      • Yazigi M.
      • Dean E.
      Culture as a variable in health research: perspectives and caveats.
      • Gutiérrez-Sánchez D.
      • Leiva-Santos J.P.
      • Sánchez-Hernández R.
      • Hernández-Marrero D.
      • Cuesta-Vargas A.I.
      Spanish modified version of the palliative care outcome scale-symptoms renal: cross-cultural adaptation and validation.

      2.8 Back translation into English

      A native English speaker translator person, fluent in Arabic, had back translated the Arabic versions of the three scales into the English language. The translator was unaware with the concepts of the anxiety scales and the original English versions.
      • Beaton D.E.
      • Bombardier C.
      • Guillemin F.
      • Ferraz M.B.
      Guidelines for the process of cross-cultural adaptation of self-report measures.
      ,
      • Beaton D.
      • Bombardier C.
      • Guillemin F.
      • Ferraz M.B.
      Recommendations for the Cross-Cultural Adaptation of Health Status Measures.
      The expert committee compared the back-translated English version of the questionnaire with the original English one, in order to check for inconsistencies and to solve any discrepancies between the versions. All ambiguities disappeared after repeating the process of forward-back translation.
      • Beaton D.E.
      • Bombardier C.
      • Guillemin F.
      • Ferraz M.B.
      Guidelines for the process of cross-cultural adaptation of self-report measures.
      • Beaton D.
      • Bombardier C.
      • Guillemin F.
      • Ferraz M.B.
      Recommendations for the Cross-Cultural Adaptation of Health Status Measures.
      • Al-Bannay H.
      • Jarus T.
      • Jongbloed L.
      • Yazigi M.
      • Dean E.
      Culture as a variable in health research: perspectives and caveats.
      • Gutiérrez-Sánchez D.
      • Leiva-Santos J.P.
      • Sánchez-Hernández R.
      • Hernández-Marrero D.
      • Cuesta-Vargas A.I.
      Spanish modified version of the palliative care outcome scale-symptoms renal: cross-cultural adaptation and validation.
      • Maneesriwongul W.
      • Dixon J.K.
      Instrument translation process: a methods review.
      • Nejjari C.
      • El Fakir S.
      • Bendahhou K.
      • et al.
      Translation and validation of European organization for research and treatment of cancer quality of life Questionnaire -C30 into Moroccan version for cancer patients in Morocco.

      2.9 Sample 2

      We conducted another cross-sectional study in May 2018 on a sample of Lebanese patients attending psychology clinic that enrolled 155 participants. To ensure the validity of the results, the scales was tested on another sample (sample 2), independent from the first one. Patients filled a questionnaire through a face-to-face interview.

      2.10 Statistical analyses

      The SPSS software version 23 was used for data analysis. A descriptive analysis were done using the counts and percentages for categorical variables and mean and standard deviation for continuous measures. The anxiety scales' validity was tested in two different methods. First, construct validity was determined by an exploratory factor analysis, using the principal components analysis technique (Sample 1): The Bartlett's test of sphericity and Kaiser-Meyer-Olkin measure of sampling adequacy were confirmed to be adequate. The number of factors retained corresponded to Eigenvalues higher than one. Items with factor loading >0.4 were considered as belonging to a factor. The Cronbach's alpha values and the Intraclass correlation coefficient were used to evaluate the internal consistency of the scales. An ICC >0.7 indicate a good reproducibility.
      • Terwee C.B.
      • Bot S.D.
      • de Boer M.R.
      • et al.
      Quality criteria were proposed for measurement properties of health status questionnaires.
      Second, a confirmatory factor analysis was carried out in Sample 2 using the maximum likelihood method for discrepancy function to assess the structure of the instrument. We also reported several goodness-of-fit indicators: the Relative chi square (x2/df), the Root Mean Square Error of Approximation (RMSEA), the Goodness of Fit Index (GFI) and the Adjusted Goodness of Fit Index (AGFI). The value of ×2 divided by the degrees of freedom (x2/df) has a low sensitivity to sample size and may be used as an index of goodness of fit (cut-off values:<2–5). The RMSEA tests the fit of the model to the covariance matrix. As a guideline, values of<0.05 indicate a close fit and values below 0.11 an acceptable fit. The GFI and AGFI are chi-square-based calculations independent of degrees of freedom. The recommended thresholds for acceptable values are ≥0.90.
      • Marsh Herb
      • Hau K.T.
      • Wen Z.
      In search of golden rules: comment on hypothesis-testing approaches to setting cutoff values for fit indexes and dangers in overgeneralizing Hu and Bentler's (1999) findings.
      The Receiver-Operating Characteristics (ROC) curve was sketched in order to determine the cutoff point of whether the presence of anxiety would be predicted or not with a great percentage. The sensitivity and specificity were calculated to assess criterion validity.

      3. Results

      The sociodemographic characteristics of the participants are summarized in Table 1. The results showed that the mean age of the participants was 28.08 ± 16.79 years, with 63.9% females. The majority (75.7%) had a university level of education, unemployed (68.8%), single (72.6%), with a low monthly income (<1000 USD) (73.5%). Only 5.2% of the participants had a family history of psychiatric illnesses, whereas 11.8% had a history of medical illness.
      Table 1Sociodemographic characteristics of the sample population.
      Frequency (%)
      Gender
       Male480 (36.1%)
       Female848 (63.9%)
      Education level
       Illiterate13 (1.0%)
       Primary21 (1.6%)
       Complementary64 (4.8%)
       Secondary224 (16.9%)
       University883 (66.7%)
       Higher education119 (9.0%)
      Employment status
       Unemployed917 (68.8%)
       Employed415 (31.2%)
      Socioeconomic status
       < 1000$926 (73.5%)
       1000–2000 $251 (19.9%)
       > 2000 $83 (6.6%)
      Marital status
       Single963 (72.6%)
       Married334 (25.2%)
       Widowed13 (1.0%)
       Divorced17 (1.3%)
      Father education level
       Illiterate68 (5.1%)
       Primary162 (12.2%)
       Complementary279 (21.0%)
       Secondary335 (25.3%)
       University482 (36.3%)
      Mother education level
       illiterate96 (7.3%)
       Primary127 (9.6%)
       Complementary302 (22.9%)
       Secondary393 (29.8%)
       University402 (30.5%)
      Residence
       Alone95 (7.2%)
       With others1217 (92.8%)
      Personal history of medical illness
       Yes157 (11.8%)
       No1174 (88.2%)
      Family history of psychiatric illness
       Yes69 (5.2%)
       No1262 (94.8%)
      Mean ± SD
      Age (in years)28.08 ± 16.79
      Number of kids1.15 ± 1.72

      3.1 Factor analysis

      Three factor analyses for the anxiety scales were run over the whole sample (N = 1332). All of the HAM-A, STAI-A and STAI-B items could be extracted from the list. All items from all the scales did not over-correlate to each other (r > 0.9), did not have a low loading on factors (<0.3) or a low communality (a communality is the extent to which an item correlates with all other items) (<0.3). The number of loading factors, KMO and Bartlett's test of sphericity values and the Cronbach alpha values for the HAM-A scale are summarized in Table 2. For STAI-A, scale's items yielded a total of 3 factors, explaining 56.04% of the total variance (KMO = 0.953; Bartlett's test of sphericity p < 0.001). Loading factors ranged between 0.467 for item “I am relaxed” to 0.795 for item “I feel steady”. Moreover, the Cronbach's alphas were recorded as follows: factor 1 = 0.852; factor 2 = 0.855; factor 3 = 0.780; total scale = 0.928. For STAI-B, scale's items yielded a total of 3 factors, explaining 58.27% of the total variance (KMO = 0.940; Bartlett's test of sphericity p < 0.001). Loading factors ranged between 0.450 for item “I feel that difficulties are piling up so that I cannot overcome them” to 0.898 for item “I wish I could be as happy as others seem to be”. Moreover, the Cronbach's alphas were recorded as follows: factor 1 = 0.875; factor 2 = 0.839; factor 3 = 0.742; total scale = 0.898.
      Table 2Promax rotated matrix of HAMA scale factors, Sample 1, and confirmatory factor analysis parameters, Sample 2 (italics).
      ItemsFactor 1Factor 2
      Genitourinary symptoms120.881/0.401
      Cardiovascular symptoms90.821/0.584
      Autonomic symptoms130.800/0.742
      Respiratory symptoms100.774/0.633
      Gastrointestinal symptoms110.721/0.597
      Somatic (sensory)80.667/0.810
      Behavior at interview140.643/0.376
      Somatic (muscular)70.551/0.694
      Tension20.910/0.916
      Anxious mood10.903/0.842
      Depressed mood60.748/0.942
      Insomnia40.692/0.756
      Fears30.529/0.521
      Intellectual50.486/0.596
      Factor 1 = Somatic items; Factor 2 = Psychic/Psychological items.
      Cronbach's alphas: factor 1 = 0.898; factor 2 = 0.853; total scale = 0.921.
      Percentage of variance explained: 58.51%.
      Kaiser-Meyer-Olkin (KMO) = 0.947.
      Bartlett's test of sphericity = p < 0.001.

      3.2 Sample 2

      A confirmatory factor analysis was run on sample 2, using the structure obtained in Sample 1. The following results was obtained: for the HAMA scale, the Maximum Likelihood Chi-Square = 152.509 and Degrees of Freedom = 76, which gave an x2/df = 2.01. For non-centrality fit indices, the Steiger-Lind RMSEA was 0.077 [0.057–0.096]. Moreover, the Joreskog GFI equaled 0.98 and AGFI equaled 0.93.
      For the STAI-A scale the Maximum Likelihood Chi-Square = 405.995 and Degrees of Freedom = 167, which gave an x2/df = 2.43. For non-centrality fit indices, the Steiger-Lind RMSEA was 0.094 [0.082–0.108]. Moreover, the Joreskog GFI equaled 0.789 and AGFI equaled 0.734.
      For the STAI-B scale the Maximum Likelihood Chi-Square = 344.374 and Degrees of Freedom = 165, which gave an x2/df = 2.08. For non-centrality fit indices, the Steiger-Lind RMSEA was 0.087 [0.074–0.099]. Moreover, the Joreskog GFI equaled 0.806 and AGFI equaled 0.753.

      3.3 Intraclass correlation coefficient between insomnia scales

      A significantly high ICC was found between the HAM-A, STAI-A (ICC = 0.709) and STAI-B (0.704). In addition, a significantly high ICC was found between the STAI-A and B scales (ICC = 0.884) (Table 3).
      Table 3Intraclass correlation coefficient between insomnia scales.
      HAMASTAI-ASTAI-B
      HAMAICC (CI)N/A0.709 (0.676–0.739)0.704 (0.671–0.734)
      p-value<0.001<0.001
      STAI-AICC (CI)0.709 (0.676–0.739)N/A0.884 (0.871–0.896)
      p-value<0.001<0.001
      STAI-BICC (CI)0.704 (0.671–0.734)0.884 (0.871–0.896)N/A
      p-value<0.001<0.001
      ICC: Intraclass Correlation coefficient; CI: Confidence interval.
      Numbers in bold indicate significant p-values.

      3.4 ROC curves

      The receiver operating characteristic (ROC) curve of the anxiety score as calculated by the HAM-A scale, comparing patients with a physician diagnosis of anxiety to healthy ones, showed that the area under the curve was high = 0.795 [0.760–0.830] (P < 0.001); at value = 11.50, the sensitivity was 76.3% and the specificity was 71.1% (Fig. 1).
      Fig. 1
      Fig. 1ROC curve of the HAMA scale. Patients diagnosed with anxiety by the physician were analyzed. Area under the curve = 0.795 [0.760–0.830] (P < 0.001); at value = 11.50, Se = 76.3% and Sp = 71.1%.
      The ROC curve of the anxiety score as calculated by the STAI-A scale, comparing patients with a physician diagnosis of anxiety to healthy ones, showed that the area under the curve was high = 0.771 [0.732–0.810] (P < 0.001); at value = 42.50, the sensitivity was 71.3% and the specificity was 69.1% (Fig. 2).
      Fig. 2
      Fig. 2ROC curve of the STAI-A scale. Patients diagnosed with anxiety by the physician were analyzed. Area under the curve = 0.771 [0.732–0.810] (P < 0.001); at value = 42.50, Se = 71.3% and Sp = 69.1%.
      The ROC curve of the anxiety score as calculated by the STAI-B scale, comparing patients with a physician diagnosis of anxiety to healthy ones, showed that the area under the curve was high = 0.779 [0.741–0.817] (P < 0.001); at value = 42.50, the sensitivity was 73.1% and the specificity was 71.6% (Fig. 3).
      Fig. 3
      Fig. 3ROC curve of the STAI-B scale. Patients diagnosed with anxiety by the physician were analyzed. Area under the curve = 0.779 [0.741–0.817] (P < 0.001); at value = 45.50, Se = 73.1% and Sp = 71.6%.

      3.5 Face validity

      When comparing the scales scores between patients with and without physician diagnosis of anxiety, the results showed that significantly higher means HAM-A, STAI-A and B scores were found in patients with a physician diagnosis of anxiety compared to those without the diagnosis (p < 0.001 for the three scales) (Fig. 4).
      Fig. 4
      Fig. 4Comparison of scales scores between patients with and without physician diagnosis of anxiety.

      4. Discussion

      The Arabic versions of the HAM-A, STAI-A and B scales was validated in the current study for use among the Lebanese population. The results showed a high reliability and validity of these scales that provide an initial evidence that could be used as a screening instrument for anxiety in Lebanon. The translation process was conducted by independent translators, the point that decreases the subjectivity of the scales’ adaptation. A comparison of the fit of the form obtained through the confirmatory factor analysis revealed that the 2 factors for HAM-A, 3 factors for STAI-A and 4 factors for STAI-B had high fit indices.

      4.1 Validation of the scale

      The construct validity of the STAI-A and B scales were adequate because items converged over three factors for STAI-A and 4 factors for STAI-B, with adequate factor loadings for all items. The internal consistency of both scales was similar to that obtained in other translated versions for state (Cronbach alpha of 0.93 for state and 0.92 for trait scales in Greece
      • Fountoulakis K.N.
      • Papadopoulou M.
      • Kleanthous S.
      • et al.
      Reliability and psychometric properties of the Greek translation of the State-Trait Anxiety Inventory form Y: preliminary data.
      and 0.93 to 0.95 for state and 0.91 to 0.93 for trait anxiety in a group of Lebanese and American students
      • Abdullatif Q.A.
      Adaptation of the State Trait Anxiety Inventory in Arabic: A Comparison with the American STAI.
      ), but lower to that obtained in. The results of the Arabic version of the STAI validity and reliability, had been similar to the psychometric properties reported by other studies.
      • Fountoulakis K.N.
      • Papadopoulou M.
      • Kleanthous S.
      • et al.
      Reliability and psychometric properties of the Greek translation of the State-Trait Anxiety Inventory form Y: preliminary data.
      ,
      • Bieling P.J.
      • Antony M.M.
      • Swinson R.P.
      The State-Trait Anxiety Inventory, Trait version: structure and content re-examined.
      ,
      • Barnes L.L.
      • Harp D.
      • Jung W.S.
      Reliability generalization of scores on the Spielberger state-trait anxiety inventory.
      Factor analysis indicated that a three-factor for STAI-A and a four-factor for STAI-B provide the best explaining criteria of anxiety enclosing the state and traits subscales. Different models were detected in other studies; Abdullatif
      • Abdullatif Q.A.
      Adaptation of the State Trait Anxiety Inventory in Arabic: A Comparison with the American STAI.
      had found two and three factors for STAI-A and STAI-B for American and Lebanese samples. In a Korean study,
      • Bieling P.J.
      • Antony M.M.
      • Swinson R.P.
      The State-Trait Anxiety Inventory, Trait version: structure and content re-examined.
      factor analysis had revealed two factors, while a single factor and 2 factor models was revealed by the confirmatory factor analysis. These variations might be due to cultural differences between countries; in fact, the experience and expression of emotions differ from person to other due to the influence of cultural background.
      • Hofmann S.G.
      • Hinton D.E.
      Cross-cultural aspects of anxiety disorders.
      The physiology of the illness syndromes and social context depend on the cultural beliefs that varied across person, thus anxiety disorders are strongly related to racial, ethnic and cultural factors.
      • Hinton D.E.
      Multicultural challenges in the delivery of anxiety treatment.
      The construct validity of the HAM-A scale was also adequate because items converged over two factors (Somatic and Psychic/Psychologic), with adequate factor loadings for all items, similar to the results obtained from previous research in adults.
      • Hamilton M.
      The assessment of anxiety states by rating.
      ,
      • Hofmann S.G.
      • Anu Asnaani M.A.
      • Hinton D.E.
      Cultural aspects in social anxiety and social anxiety disorder.
      The internal consistency of the HAM-A scale was excellent (0.921), suggesting that this scale's items are able to screen for anxiety among the Lebanese population in an excellent way.

      4.2 Validity

      The construct validity of the Arabic version of these scales was addressed by calculating the sensitivity and specificity of the scale. This study is the first to our knowledge to assess this property during the validation process of these scales. We obtained good areas under the curves, sensitivities and specificities for all three scales. These good results may be due to the fact that we compared used the physician diagnosis variable to compare between individuals with anxiety and those without.

      4.3 Limitations

      The current study has several limitations. An information bias could have occurred since the patients might not have understood the questions well or over/underestimated the answers to some questions. A selection bias is possible because of the refusal rate. The levels of experiential and expressive anxiety are gender different thus our results could be affected by the unequal number of males and females. In addition, the majority of the participants were young according to the mean age, therefore, future studies should be targeted towards older adults. Despite these limitations, the sample size is acceptable and the study results can be extrapolated to the whole population because of the study design used.

      5. Conclusion

      Since language barriers are an important obstacle to proper medical communication and management, translation of the HAM-A, STAI-A and B scales to Arabic and validation of the Arabic forms was essential. The linguistically validated Arabic versions of these scales can be used to screen for anxiety among the Lebanese populations. Further studies are needed in other Arabic-speaking countries to confirm our findings and extrapolate the use of the Arabic versions of these scales.

      Funding sources

      None.

      Declaration of competing interest

      The authors have nothing to disclose.

      Acknowledgments

      The authors would like to thank Mrs Timi Most for her support and help towards the publication of this paper.

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