Fear among Syrians: A Proposed Cutoff Score for the Arabic Fear of COVID-19 Scale.

COVID-19 pandemic has led to psychological health issues one of which is fear. This study validates the Arabic version of the fear of COVID-19 scale and suggests a new cutoff score to measure fear of COVID-19 among the Syrian Population. A total of 3989 participants filled an online survey consisting of socio-demographic information, the fear of COVID-19 scale, the patient health questionnaire 9-item, and the generalized anxiety disorder 7-item. Receiver operating characteristic analysis was used to define cutoff scores for the fear of COVID-19 scale in relation to generalized anxiety disorder 7-item and the patient health questionnaire 9-item. The Cronbach α value of the Arabic fear of COVID-19 scale was 0.896, revealing good stability and internal consistency. The inter-item correlations were between [0.420-0.868] and the corrected item-total correlations were between [0.614-0.768]. A cutoff point of 17.5 was deduced from the analysis. According to the deduced cutoff point, 2111(52.9%) were categorized as extreme fear cases. This cutoff score deduced from this study can be used for screening purposes to distinguish community members that may be prone to developing extreme fear of COVID-19. Therefore, early preventive and supportive measures can then be delivered.

Introduction

The novel Coronavirus disease-2019 (COVID-19) is a momentous danger to humanity’s health that has emerged as an outbreak. The first COVID-19 incident was noted in Wuhan, China in December 2019. This virus quickly crossed the borders, spreading all over the world, resulting in a never-ending pandemic burdened with the results of morbidity and mortality [1]. There are live updates of the latest cases, and deaths every second of the day, as well as official briefings, and prognostications about future cataclysmic events [2]. Enumeration of all deaths, compared to the 0.28% crude mortality rate, which will continue to rise as more infections and deaths occur, produces an image of excess death, capturing both the direct burden of the pandemic and its indirect mortality burden [3,4]. 22 March 2020 marked the first officially reported COVID-19 case in Syria [5]. The numbers have escalated since then with Syria now entering its third wave [6-8].

As the pandemic has embedded misconceptions around COVID-19, strict precautionary measures have been adopted by governments, such as physical distancing, self-isolation, and quarantine [9]. These measures were implemented to curtail the tide of the pandemic when no treatments or vaccines were available during the time of survey administration. During the Syrian lockdown, many streets have become ghost towns. Flights all over the globe have ceased. Business and medical conferences have been postponed to the unknown future. Mosques, museums, parks, schools, and universities have been closed and abandoned. Grocery and pharmacy stores are being cleared of over-the-counter medications, disinfectants, supplements, and herbal remedies. Households are stacked to the brim with groceries and toiletries, in preparation for a long draconian lockdown that may never end. National closures of businesses, public facilities, and entertainment have resulted in less currency in circulation. All the above have shocked the economy drastically. The effects of the mass media and governments have had a toll on society, probably for several years to come; their disruptive actions are eliciting more damage to people around the globe than COVID-19. As a major health issue, the COVID-19 pandemic has triggered a multilevel global crisis, affecting an individual’s physical and psychological mental health. Thus, researchers are expressing concerns related to COVID-19 adverse effects on society’s mental health and psychological well-being [10-22].

One of these psychological impacts is fear, a vital emotion necessary for an individual’s survival by arousing adaptive defense responses against potentially threatening events or danger [23]. The current threatening event is COVID-19, a prolonged worry or negative emotional reaction towards contracting COVID-19, morbidity, and mortality [24]. Added to the previous are the effects of the pandemic on our daily habits including unemployment, working from home, home-schooling, and lack of socializing. Fear is becoming a critical concern, as the pandemic continues to spread high infection, morbidity, and mortality cases. These concerns have pushed researchers to assess the fear of COVID-19 in different regions of the world and identify the possible triggers [25].

Fear may contribute to the development of mental health disorders or further deteriorate pre-existing psychiatric symptoms such as generalized anxiety disorders, depression, and post-traumatic stress disorder, and even suicide [12,26,27]. A recent study has developed the Fear of COVID-19 Scale (FCV-19S) as a means of boosting the medical practice that is dedicated to preventing the spread of COVID-19 cases and treating them [28]. The psychometric evidence of the FCV-19S demonstrated satisfactory results [29-35]. A few studies thereafter have validated the questionnaire in various languages and examined associations with socio-demographic characteristics [33,36-42]. However, only one study as of yet has proposed a cutoff score for the FCV-19S [43]. Given that Syria is one of the most vulnerable countries in the world to be tormented by mental health disorders due to both COVID-19 and war. The aim of the study is to assess the fear regarding COVID-19 among Syrians, validate the FCV-19S, and identify an appropriate cutoff score to differentiate individuals with normal fear of COVID-19 response from ones encountering extreme fear.

Materials and methods

Study design, setting, and participants

A web-based cross-sectional study was conducted using an Arabic questionnaire over a period of 12 days between May 2 and May 14 of 2020. Inclusion criteria: Participants aged 18 and above, residents in Syria, and full completion of the survey. A convenience sampling method was used in the study. The questionnaire was uploaded over several popular social media apps. Once informed consent was received, participants filled in their socio-demographic information including sex, age, place of residence, education level, occupation, and economic status. The socio-demographic questions in Arabic and English are displayed in S1 and S2 Tables. Participants were also asked about the history of chronic diseases. The total dataset of 3989 participants was used to validate the Arabic version of the FCV-19S.

Development of the arabic FCV-19S

The English FCV-19S was translated into Arabic through a forward-backward translation technique [28]. The FCV-19S was translated into Arabic by two medical translators who are fluent in both Arabic and English. The authors, who are fluent in Arabic and English, revised the Arabic translation and no errors were identified with the translation. The final copy of the Arabic translation was back-translated to English by another medical translator who was unacquainted with the original English FCV-19S. A comparison of the forward and backward scale translations to identify any differences and cultural convenience was done. A pilot study including 20 volunteers was undertaken to assess the scale’s reliability, clarity, relevance, and acceptability of the survey, who were eliminated from the statistical analysis to avoid bias. No modifications were required. The Arabic version of the FCV-19S is provided in S3 Table.

Measures

The FCV-19S (after translation) was used to evaluate the symptoms of fear. The FCV-19S is a one-dimensional scale that measures one’s fear level of COVID-19 it consists of 7 items. Each item is rated on a 5-point Likert scale with 1 representing strongly disagree and 5 representing strongly agree, providing a 7 to 35 total score range. The higher the score the greater the levels of fear of COVID-19 are [41].

The Arabic Patient Health Questionnaire 9-item (PHQ-9) was used in the study to assess depression symptom severity [44]. Items on the PHQ-9 were scored over a 4-point Likert scale: 0 = not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day), providing a 0–27 severity score range. The scores were categorized into 5 groups: none (0–4), mild (5–9), moderate (10–14), moderately severe (15–19), and severe (20–27).

The Arabic Generalized Anxiety Disorder 7-item (GAD-7) was used in this study to assess anxiety symptom severity [45]. Items on the GAD-7 were scored over a 4-point Likert scale: 0 = not at all, 1 = several days, 2 = more than half the days, 3 = nearly every day, providing a 0–21 severity score range. The Gad-7 is a self-rated scale used to evaluate the severity of the 4 most common anxiety disorders (Generalized Anxiety Disorder, Panic Disorder, Social Phobia, and Post Traumatic Stress Disorder), a cutoff score of 0–4 indicates no anxiety symptoms. The scores were categorized into 4 groups: none (0–4), mild (5–9), moderate (10–14), and severe (15–21) [46].

Ethics

Ethical approval was granted by the Institutional Review Board (IRB) of the Faculty of Medicine, Syrian Private University. The study was not granted a registered number.

Statistical analysis

Descriptive analysis, including frequencies, percentages, means, and standard deviations (SD) were applied. The Cronbach’s α test and inter-item correlation were used to assess the internal consistency, with satisfactory reliability set at ≥ 0.70 and between 0.20 and 0.40 respectively [47,48]. The corrected item-total correlation was used to assess the coherence of the FCV-19S (values > 0.4 are acceptable). The item factor loadings, average variance extracted (AVE), and composite reliability (CR) were used to assess the convergent validity of the FCV-19S. The Heterotrait-Monotrait (HTMT) was used to assess the discriminant validity of the FCV-19S. A CR value between 0.7 and 0.9, AVE value > 0.5, and discriminant validity < 0.85 were set for this study [49-51]. Cutoff scores were deduced from receiver operating characteristic (ROC) analysis for the FCV-19S scale in association with GAD-7 and PHQ-9 (external criteria). The Youden-Index was used to deduce the optimal cutoff score for the Arabic scale and to lower the risk of miscategorization. A dichotomous variable was created out of the total for both GAD-7 and PHQ-9 using the cutoff point of 10 to assess anxiety and depressive symptoms respectively [44,46]. After determining the cutoff points, participants with a total score above the deduced cutoff value were categorized as cases with extreme fear, while those below it were categorized under normal fear of COVID-19. The Statistical Package for Social Sciences version 25.0 (SPSS Inc., Chicago, IL, United States) was used.

Results

Socio-demographic characteristics of participants

Of 5000 total participants invited to take part in the study, 4,430 gave informed consent. A final sample size of 3989 participants (response rate = 79.8%) met the inclusion criteria for the study. The 441 participants who did not meet the inclusion criteria were either below 18, residing outside Syria, or uncompleted survey. Most participants were female 2935 (73.5%), single 3096 (77.6%), students 2397 (60.1%), and residing in Damascus 1412 (35.4%). Ages ranged between 18 and 70 years. The major age group was 18–25 years 2870 (71.9%). A total of 416 (10.4%) and 1522 (38.1%) participants reported their economic status as under poor and moderate respectively. 556 (15.9%) mentioned a history of chronic diseases Table 1.

Table 1

Participants socio-demographics.

Gender (%)	Male	1054 (26.4)
	Female	2935 (73.5)
Age (%)	18–25	2870 (71.9)
	26–34	685 (17.2)
	35–44	261(6.5)
	45–54	121 (3.0)
	55 <	52 (1.4)
Social Status (%)	Single	3096 (77.6)
	Married	714 (17.9)
	Other	179 (4.5)
Economic Status (%)	1 Excellent	251 (6.3)
	2 Good	1800 (45.1)
	3 Moderate	1522 (38.1)
	4 Poor	416 (10.4)
Chronic disease(s) (%)	Yes	556 (13.9)
	No	3433 (86)
Education (%)	Primary School	21 (0.5)
	Intermediate School	115 (2.9)
	Secondary school	370 (9.3)
	College/ University	3271 (82)
	Master’s degree	185 (4.6)
	PhD	27 (0.7)
Occupation (%)	Health care worker	259 (6.5)
	Government institution	239 (6.0)
	Private institution	202 (5.1)
	Business	202 (5.1)
	Military	35 (0.9)
	Student	2397 (60.1)
	Other	655 (16.4)
Household members (%)	Alone	54 (1.4)
	1–5	2474 (62)
	>5	1461 (36.6)

1Poor: Income does not provide essential needs for the family.

1Excellent: Income provides luxury requirements.

2Good: Income provides essential needs and some luxury requirements.

3Moderate: Income provides essential needs for the family but no more.

4Poor: Income does not provide essential needs for the family.

Validity and cutoff Score analysis

The FCV-19S scores ranged between 7 and 35, the mode score was 14, and the mean score was 18.5 (± 6.009) Fig 1. Participants’ responses to the FCV-19S are shown in Table 2. The Cronbach α value of the Arabic FCV-19S was 0.896, revealing good stability and internal consistency. The inter-item correlations were between [0.420–0.868] and the corrected item-total correlations were between [0.614–0.768] Table 3. The CR value for all items of the FCV-19S was 0.934, exceeding the set threshold, deeming the CR unreliable. The AVE value for all items of the FCV-19S was good (0.672). The value 0.820 was a measure of reasonable discriminant validity of the FCV-19S.

Fig 1

Participant’s FCV-19S score distribution.

Table 2

Participants response to FCV-19S.

	Response to FCV-19S
FCV-19S	Totally disagree (%)	Disagree (%)	Neutral (%)	Agree (%)	Totally Agree (%)
1- I am often afraid of the emerging COVID-19	261 (6.5)	826 (20.7)	1557 (39.0)	951 (23.8)	394 (9.9)
2- I feel uncomfortable when I think about the new COVID-19	279 (7.0)	906 (22.7)	1115 (28.0)	1228 (30.8)	461 (11.6)
3- My hands get sweaty when I think about the new COVID-19	962 (24.1)	1983 (49.7)	719 (18.0)	119 (3.0)	206 (5.2)
4- I am afraid of dying due to infection with the emerging COVID-19	685 (17.2)	1579 (39.6)	892 (22.4)	463 (11.6)	370 (9.3)
5- I feel anxious and nervous when I follow news or posts about COVID-19 on social media	390 (9.8)	968 (24.3)	1002 (25.1)	1070 (26.8)	559 (14.0)
6- I cannot sleep because of my anxiety about infection with the emerging COVID-19	1045 (26.2)	1875 (47.0)	688 (17.2)	152 (3.8)	229 (5.7)
7- I feel my heart racing and palpitations when I think about the emerging COVID-19	1023 (25.6)	1843 (46.2)	670 (16.8)	211 (5.3)	242 (6.1)

Table 3

FCV-19S construct validity analysis.

Items	Factor loading	Corrected item-total correlation	Cronbach’s alpha	Inter-item correlation range	M(SD)	Skewness	kurtosis	Kaiser-Meyer-Olkin
1- I am often afraid of the emerging COVID-19	0.843	0.661	0.896	0.423- 0.717	3.1 (1)	-0.021	-0.470	0.864
2- I feel uncomfortable when I think about the new COVID-19	0.877	0.655		0.424–0.717	3.17 (1.1)	-0.146	-0.801
3- My hands get sweaty when I think about the new COVID-19	0.877	0.723		0.420–0.791	2.15 (1)	1.147	1.418
4- I am afraid of dying due to infection with the emerging COVID-19	0.551	0.724		0.513–0.612	2.576 (1.2)	0.607	-0.450
5- I feel anxious and nervous when I follow news or posts about COVID-19 on social media	0.715	0.614		0.420–0.574	3.11 (1.2)	-0.067	-0.973
6- I cannot sleep because of my anxiety about infection with the emerging COVID-19	0.905	0.763		0.429–0.868	2.16 (1)	1.114	1.077
7- I feel my heart racing and palpitations when I think about the emerging COVID-19	0.889	0.768		0.453–0.868	2.2 (1.1)	1.050	0.749

The responses to the GAD-7 scale were categorized into two groups: non-anxious symptoms (score < 9) and anxious symptoms (9 < score ≤ 21). The responses to the PHQ-9 scale were categorized into two groups: non-depressed symptoms (score < 9) and depressed symptoms (9 < score ≤ 27) Table 4.

Table 4

Classification of participants according to FCV-19S, GAD-7, and PHQ-9 cutoff points.

	Yes (%)	No (%)
FCV-19S	211 (52.9)	1878 (47.1)
GAD-7	1484 (37.2)	2505 (62.8)
PHQ-9	2176 (54.6)	1813 (45.4)

ROC analysis was used to evaluate the efficacy of the FCV-19S in predicting anxiety and depression factors. The proposed cutoff score was determined by the optimal sensitivity and specificity level, Table 5, revealing the following

Table 5

Prediction validity of the FCV-19S.

	FCV-19S Score	Sensitivity	Specificity	AUC	CI (95%)	p-value	Youden’s Index
Anxiety	18.5	0.532	0.575	0.560	[0.541, 0.578]	< 0.001	0.107
Depression	17.5	0.551	0.496	0.520	[0.502, 0.538]	< 0.001	0.047

Unsatisfactory predictive power for the FCV-19S in disclosure of anxiety symptoms assessed using GAD-7 was found. The best cutoff was at 18.5, with a sensitivity of 53% and specificity of 57.5%, as the area under the curve (AUC) was 0.560 with a statistical significance (p-value < 0.001), a confidence interval of 95% CI = [0.541, 0.578] Table 5 and Fig 2.

Fig 2

ROC curve of FCV-19S for anxiety.

Unsatisfactory predictive power for the FCV-19S in disclosure of depressive symptoms assessed using PHQ-9 was found. The best cutoff was at 17.5 with a sensitivity of 55.1% and specificity of 49.6%, AUC = 0.520 was statistically significant (p-value < 0.001), a confidence interval of 95% CI = [0.502, 0.538] Table 5 and Fig 3.

Fig 3

ROC curve of FCV-19S for depression.

A cutoff point of 17.5 was deduced from the anxiety and depression ROC analysis. According to the deduced cutoff point, the majority 2111(52.9%) were categorized as cases with extreme fear Table 4.

Discussion

The current study was performed to validate the Arabic version of the FCV-19S and propose a cutoff to distinguish members of the population who reacted towards COVID-19 with extreme fear from those with a normal fear reaction. Deducing a cutoff is a pivotal and familiar practice among the field of psychiatry to differentiate those into either morbid cases or nonmorbid cases [52-56]. Identifying cases and non-cases with extreme fear will allow us to stratify those in need for further assessment by a specialist in psychiatry. Once assessed, appropriate management can be given if indicated. Although many studies have used the FCV-19S to assess fear among various populations, without a cutoff score we cannot further analyze the results and compare and interpret findings with different populations [57].

Our study revealed a good internal consistency (Cronbach’s α = 0.896). Our finding was in line with other studies with a range of 0.82 to 0.88 [28,42,58,59]. The inter-item correlations were between [0.420–0.868] and the corrected item-total correlations were between [0.614–0.768], whereas it was [0.35–0.66] and [0.57–0.74] respectively in a Saudi-Arabian study [60].

ROC curves were constructed to determine the FCV-19S cutoff point. A cutoff point of 17.5 was deduced, participants scoring ≥ 17.5 were categorized as having extreme fear of COVID-19, whereas participants scoring below this threshold were categorized as having normal fear of COVID-19. Only one study has defined a cutoff for the FCV-19S, with a threshold of 16.5 and higher [43].

This study revealed a weak discriminatory ability from the AUC outcomes, whereas its accuracy was moderate in a Greek study [61]. The low precision of AUC signifies that not all individuals with depression or anxiety symptoms have an unhealthy fear of COVID-19 and vice versa. This may be attributed to over a decade of conflict and the implications it induced on the mental health of the Syrian population [62]. Thus, Syrians have countless factors contributing to their depressive and anxiety symptoms unlike the majority of the globe. Also, the FCV-19S was designed to assess fear towards COVID-19 while the GAD-7 and PHQ-9 are not aimed at assessing depression and anxiety towards the COVID-19 pandemic.

Fear of COVID-19 may be a factor that impacts an individual’s protective behaviors, including vaccination uptake [63]. Therefore, one should have a certain level of fear but not extreme fear as individuals lack the perception to respond to threats faced [64]. Our study revealed a prevalence of 52.9% of Syrians was categorized as having extreme fear towards COVID-19. The prevalence of extreme fear among Syrians was higher in comparison with the Greeks (40.3%), despite their lower cutoff. The higher prevalence among Syrians can be attributed to the devastating impacts of war, driving the country into a prolonged economic recession. The devastating conflict has resulted in a Syrian healthcare system that is drastically unequipped to restrain such a pandemic. With many healthcare professionals fleeing the country, a low number of ventilators, and many hospitals bombarded to rubble, Syrians must feel constant fear for their lives [65].

All the above factors have exacted immense effects on the mental health of Syrians. The Syrian ministry of health provides 3 hospitals for substance abuse and mental illness: Ibn Rushd Hospital in Damascus, Ibn Sina Hospital in Rural Damascus, and Ibn Khaldoun Hospital in Aleppo. Ibn Khaldoun Hospital was bombarded on 25/12/2012, leaving only 2 working hospitals. Our study showed that 54.6% and 37.2% of Syrians are suffering from moderate to severe depressive and anxiety symptoms respectively. Grievously, 90% of cases are left unattended, untreated, and unmanaged, as only 80 psychiatrists are available in Syrian territories [66,67]. We must call on national and international organizations to aid us Syrians, reconstruct mental health services, and assist in providing skilled healthcare workers for the suffering people of Syria.

Limitations

The existing study has countless limitations in its build. First, the sampling approach, convenience, may have affected the generalizability of the findings. Less educated and socially underprivileged participants were underrepresented. Second, to evaluate the representativeness of our sample, credible national Syrian data regarding demographic features of the population is required, which are currently not available. Third, the cross-sectional design limited the assessment of prospective effects of fear over time. Fourth, the proposed cutoff aimed to further make use of the scale to screen for cases with extreme fear but not for diagnostic purposes. Fifth, insufficiency of other scales assessing the same construct during the conduct of the study such as health anxiety and posttraumatic stress disorder. Sixth, the cutoff should ideally only be used on Syrian populations due to the characteristics of the participants in the study. Therefore, the proposed cutoff score must be used with attentiveness. Seventh, given the ongoing turmoil in Syria, the effects of wartime crisis perceptions concerning the COVID-19 pandemic adverse health, economic, and social ramifications on everyday life warrants further assessment.

Conclusion

This study assessed COVID-19-related fear among the Syrian population and determined a cutoff score of ≥ 17.5 with unsatisfactory predictive power for depression and anxiety. This cutoff score can be used for screening purposes to identify individuals most vulnerable to developing fear-related symptomatology. Therefore, require further assessment to identify high-risk individuals and deliver early preventive and/or supportive measures. However, the Syrian healthcare system is under constant strain due to the burdens of war and the COVID-19 pandemic, and such measures may only exist in our imaginations.

English-version of the socio-demographic characteristics questions.

(DOCX)

Click here for additional data file.

Arabic-version of the socio-demographic characteristics questions.

(DOCX)

Click here for additional data file.

Arabic-version of FCV-19S.

(DOCX)

Click here for additional data file.

25 May 2021

PONE-D-21-14780

Fear among Syrians: a Proposed Cutoff Score and Validation of the Arabic Fear of COVID-19 Scale- A National Survey

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Reviewer #1: This is a well reported study. However, the following points need clarification:

1) The authors state that sample size was calculated for a population of 17, 500, 657 people (line 100). It is well known that much less Syrians were living in Syria in 2020.

2) The authors imply that they tested a sample that is representing all Syrians. It is not clear how the 5000 participants were chosen to be invited to take part in the study.

3) This is web-based cross-sectional study employing social media. It is unlikely that all the people appearing in a random sample would have an online access to social media.

4) There is a contradiction between the statement (The original FCV-19S was translated into Arabic using a forward-backward translation technique – line 110) and the statement (For this study, we used the Arabic version of FCV-19S, which was validated in a previous study – line 123).

5) The title “Fear among Syrians: a Proposed Cutoff Score and Validation of the Arabic Fear of COVID-19 Scale- A National Survey” implies that that the results of this survey could generalised to the whole Syrian nation. This does not seem to be the case as the authors acknowledge that They has used “convenience sampling” – line 244, and the results cannot be generalized. This study, thus, cannot be described as a national survey in the title and in the text.

6) the emphasis in the title on a “proposed cut-off point” that is useless is not appropriate.

Reviewer #2: I believe that the present study can add merits to the present understanding of fear toward COVID-19. To the best of my knowledge, although many studies have translated and validated the Fear of COVID-19 Scale (FCV-19S), none have proposed a cutoff for the FCV-19S. Therefore, the major contribution of the present study is the proposed cutoff with using previous standardized fear scales. Moreover, the present study has the strengths of (1) rigorous translation for the FCV-19S, (2) large sample size of 3989, and (3) adequate statistical methods. Therefore, I read this paper with greatest interests. However, several points should be addressed before I recommend publication. Please see my comments below.

1. I would like the authors to provide more information regarding the psychometric evidence of the FCV-19S. The following references are recommended to be included in a revision.

Chang, K.-C., Hou, W.-L., Pakpour, A. H., Lin, C.-Y., Griffiths, M. D. (accepted). Psychometric testing of three COVID-19-related scales among people with mental illness. International Journal of Mental Health and Addiction.

Pakpour, A. H., Griffiths, M. D., Chang, K.-C., Chen, Y.-P., Kuo, Y.-J., & Lin, C.-Y. (2020). Assessing the fear of COVID-19 among different populations: A response to Ransing et al. (2020). Brain, Behavior, and Immunity, 89, 524-525.

Andrade, E. F., Pereira, L. J., Oliveira, A., Orlando, D. R., Alves, D., Guilarducci, J. S., & Castelo, P. M. (2020). Perceived fear of COVID-19 infection according to sex, age and occupational risk using the Brazilian version of the Fear of COVID-19 Scale. Death studies, 1–10. Advance online publication. https://doi.org/10.1080/07481187.2020.1809786

Haktanir, A., Seki, T., & Dilmaç, B. (2020). Adaptation and evaluation of Turkish version of the fear of COVID-19 Scale. Death studies, 1–9. Advance online publication. https://doi.org/10.1080/07481187.2020.1773026

Caycho-Rodríguez, T., Valencia, P. D., Vilca, L. W., Cervigni, M., Gallegos, M., Martino, P., Barés, I., Calandra, M., Rey Anacona, C. A., López-Calle, C., Moreta-Herrera, R., Chacón-Andrade, E. R., Lobos-Rivera, M. E., Del Carpio, P., Quintero, Y., Robles, E., Panza Lombardo, M., Gamarra Recalde, O., Buschiazzo Figares, A., White, M., … Burgos Videla, C. (2021). Cross-cultural measurement invariance of the fear of COVID-19 scale in seven Latin American countries. Death studies, 1–15. Advance online publication. https://doi.org/10.1080/07481187.2021.1879318

Soares, F. R., Afonso, R. M., Martins, A. P., Pakpour, A. H., & Rosa, C. P. (2021). The fear of the COVID-19 Scale: validation in the Portuguese general population. Death studies, 1–7. Advance online publication. https://doi.org/10.1080/07481187.2021.1889722

Moreta-Herrera, R., López-Calle, C., Caycho-Rodríguez, T., Cabezas Guerra, C., Gallegos, M., Cervigni, M., Martino, P., Barés, I., & Calandra, M. (2021). Is it possible to find a bifactor structure in the Fear of COVID-19 Scale (FCV-19S)? Psychometric evidence in an Ecuadorian sample. Death studies, 1–11. Advance online publication. https://doi.org/10.1080/07481187.2021.1914240

2. In the second paragraph of the Introduction, the authors should include the following references, which also support the statement that COVID-19 impacts on individuals' physical and mental health.

Fung, X. C. C.#, Siu, A., Potenza, M. N., O'Brien, K. S., Latner, J. D., Chen, C.-Y., Chen, I.-H., & Lin, C.-Y. (2021). Problematic use of internet-related activities and perceived weight stigma in schoolchildren: A longitudinal study across different epidemic periods of COVID-19 in China. Frontiers in Psychiatry.

Malik, S., Ullah, I., Irfan, M., Ahorsu, D. K., Lin, C.-Y., Pakpour, A. H., Griffiths, M. D., Rehman, I. U., & Minhas, R. (2021). Fear of COVID-19 and workplace phobia among Pakistani doctors: A survey study. BMC Public Health, 21, 833.

Mahmoudi, H., Saffari, M., Movahedi, M., Sanaeinasab, H., Rashidi-Jahan, H., Pourgholami, M., Poorebrahim, A., Barshan, J., Ghiami, M., Khoshmanesh, S., Potenza, M. N., Lin, C.-Y.*, Pakpour, A. H.* (2021). The mediating role of mental health in associations between COVID-19-related self-stigma, PTSD, quality of life and insomnia among patients recovered from COVID-19. Brain and Behavior, 11, e02138.

Chen, C.-Y., Chen, I.-H., Hou, W.-L., Potenza, M. N., O'Brien, K. S., Lin, C.-Y., & Latner, J. D. (2021). The relationship between children’s problematic Internet-related behaviors and psychological distress during the onset of the COVID-19 pandemic: A longitudinal study. Journal of Addiction Medicine.

Chen, C.-Y., Chen, I.-H., Pakpour, A. H., Lin, C.-Y., & Griffiths, M. D. (2021). Internet-related behaviors and psychological distress among schoolchildren during the COVID-19 school hiatus. Cyberpsychology, Behavior, and Social Networking.

Chen, I.-H., Chen, C.-Y., Pakpour, A. H., Griffiths, M. D., Lin, C.-Y., Li, X.-D., Tsang, H. W. H. (2021). Problematic internet-related behaviors mediate the associations between levels of internet engagement and distress among schoolchildren during COVID-19 lockdown: A longitudinal structural equation modeling study. Journal of Behavioral Addictions, 10(1), 135-148.

Pramukti, I., Strong, C., Sitthimongkol, Y., Setiawan, A., Pandin M. G. R., Yen, C.-F., Lin, C.-Y., Griffiths, M. D., Ko, N.-Y. (2020). Anxiety and suicidal thoughts during the COVID-19 pandemic: A cross-country comparison among Indonesian, Taiwanese, and Thai university students. Journal of Medical Internet Research, 22(12), e24487.

Chen, C.-Y., Chen, I.-H., O'Brien, K. S., Latner, J. D., & Lin, C.-Y. (2021). Psychological distress and internet-related behaviors between schoolchildren with and without overweight during the COVID-19 outbreak. International Journal of Obesity, 45(3), 677-686.

Ahorsu, D. K., Lin, C.-Y., Pakpour, A. H. (2020). The association between health status and insomnia, mental health, and preventive behaviours: The mediating role of fear of COVID-19. Gerontology and Geriatric Medicine, 6, 1-9.

Chang, K.-C., Strong, C., Pakpour, A. H., Griffiths, M. D., & Lin, C.-Y. (2020). Factors related to preventive COVID-19 infection behaviors among people with mental illness. Journal of the Formosan Medical Association, 119(12), 1772-1780.

Lin, C.-Y., Broström, A., Griffiths, M. D., & Pakpour, A. H. (2020). Investigating mediated effects of fear of COVID-19 and COVID-19 misunderstanding in the association between problematic social media use and distress/insomnia. Internet Interventions, 21, 100345.

Chen, I.-H., Chen, C.-Y., Pakpour, A. H., Griffiths, M. D., & Lin, C.-Y. (2020). Internet-related behaviors and psychological distress among schoolchildren during COVID-19 school suspension. Journal of the American Academy of Child and Adolescent Psychiatry, 159(10), 1099-1102.

Lin, C.-Y. (2020). Social reaction toward the 2019 Novel Coronavirus (COVID-19). Social Health & Behavior, 3, 1-2.

3. The authors said "For this study, we used the Arabic version of FCV-19S, which was validated in a previous study.(31)". However, they also provide a section to describe the translation procedure. This is somewhat confusing because I cannot know whether the authors translated the FCV-19S by themselves or the translation descriptions are derived from the reference #31.

4. In ethics, please provide the registered number of the IRB.

5. If possible, I would like to know if there is any demographic difference between the analyzed sample (n=3989) and those who gave a consent but not used for data analysis (n=441). This can provide information to the readers regarding the sample representativeness.

6. In Discussion, the authors should mention that fear may be a factor impacts an individual's protective behaviors, including vaccination uptake using the references I provided below. Therefore, one should have a certain level of fear but not an overwhelming fear.

Wang, P.-W., Ahorsu, D. K., Lin, C.-Y., Chen, I.-H., Yen, C.-F., Kuo, Y.-J., Griffiths, M. D., & Pakpour, A. H. (2021). Motivation to Have COVID-19 Vaccination Explained Using an Extended Protection Motivation Theory Among University Students in China: The Role of Information Sources. Vaccines, 9, 380.

7. Following my previous comment, the authors can make some comments regarding the low willingness of vaccination uptake in some countries (Kukreti et al., 2021), and thus monitoring fear is important.

Kukreti, S., Lu, M.-L., Lin, Y.-H., Strong, C., Lin, C.-Y., Ko, N.-Y., Chen, P.-L., & Ko, W.-C. (2021). Willingness of Taiwan’s healthcare workers and outpatients to vaccinate against COVID-19 during a period without community outbreaks. Vaccines, 9(3), 246.

8. I would encourage the authors reformatted their tables as they are hard to read. Please consult some published articles in PLOS ONE to revise these tables.

9. The references are not in good shape. Specifically, the authors used "Organization WH" to indicate "World Health Organization", which is incorrect. Also, there are some repeated references in the list (e.g., #16 and #19 are the same reference). The authors should check their reference list carefully.

**********

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Reviewer #1: Yes: Adib Essali

Reviewer #2: No

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14 Jun 2021

Response letter

We would like to thank both the editor and reviewers for spending their valuable time reviewing this manuscript. We have thoroughly assessed the comments and implemented them into our revised manuscript, now that this article has been made suitable, we aspire to have this article published in your journal.

The following letter will report the responses to the reviewers’ comments.

Editor and Reviewer comments:

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Author response: We have revised the style requirements and implemented them within our manuscript.

2. We note that your Supporting Information file may include questionnaire items that may have been previously published. The reproduction of previously published work has implications for the copyright that may apply to these publications. We would be grateful if you could clarify whether you have obtained permission from the original copyright holder to republish these items under a CC BY license. If you have not obtained permission to publish these items please remove them from your manuscript. You may wish to replace the text you have removed with relevant question numbers/ brief descriptions of each item; please be sure to include any relevant references and in-text citations.

Author response: We will remove the English version of the FCV-19S from the supporting files. We mentioned in the methods clearly that we used the English version and translated it ourselves to Arabic. We apologize for accidently mentioning “For this study, we used the Arabic version of FCV-19S, which was validated in a previous study.”, we actually translated the questionnaire ourselves and validated it statistically.

3. Please amend the manuscript submission data (via Edit Submission) to include author Salma Khadem alsrouji.

Author response: We have made the necessary amendment.

4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

Author response: We agree and have done as requested above.

5.Thank you for submitting the above manuscript to PLOS ONE. During our internal evaluation of the manuscript, we found significant text overlap between your submission and the following previously published works.

- https://www.statnews.com/2020/03/16/coronavirus-serious-threat-prepare-not-overreact/

We would like to make you aware that copying extracts from previous publications, especially outside the methods section, word-for-word is unacceptable, even for works which you authored. In addition, the reproduction of text from published reports has implications for the copyright that may apply to the publications.

Please revise the manuscript to rephrase the duplicated text, cite your sources, and provide details as to how the current manuscript advances on previous work. Please note that further consideration is dependent on the submission of a manuscript that addresses these concerns about the overlap in text with published work.

We will carefully review your manuscript upon resubmission, so please ensure that your revision is thorough.

Author response: We apologise for this, we were not aware of this matter and we don’t remember seeing the above article, which was slightly confusing for us. We have revised the manuscript and have rephrased some sentences. If there are still sentences that show plagiarism, we would appreciate if you could identify them for us and we would be happy to rephrase them. Again you have our deepest apologies.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

________________________________________

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This is a well reported study. However, the following points need clarification:

Author response: We thank the reviewer for their compliment and will address the comments provided below.

1) The authors state that sample size was calculated for a population of 17, 500, 657 people (line 100). It is well known that much less Syrians were living in Syria in 2020.

Author response: We agree with this, however, there are no credible national data regarding this matter. We took this data from a fact sheet published by the World Health Organization (https://gco.iarc.fr/today/data/factsheets/populations/760-syrian-arab-republic-fact-sheets.pdf). This citation has been added to the manuscript

2) The authors imply that they tested a sample that is representing all Syrians. It is not clear how the 5000 participants were chosen to be invited to take part in the study.

Author response: We apologise for not mentioning the type of sampling. We used a convenience sampling method in the study. This has been added to the methods section. We mentioned in the limitations that credible published national data regarding the socio-demographic variables of Syrians are not available to evaluate the representativeness of our sample.

3) This is web-based cross-sectional study employing social media. It is unlikely that all the people appearing in a random sample would have an online access to social media.

Author response: We apologise for not mentioning the type of sampling. We used a convenience sampling method in the study. This has been added to the methods section.

4) There is a contradiction between the statement (The original FCV-19S was translated into Arabic using a forward-backward translation technique – line 110) and the statement (For this study, we used the Arabic version of FCV-19S, which was validated in a previous study – line 123).

Author response: We apologise the mistake, we did not use the validated Arabic version of FCV-19S. This has been removed from the text.

5) The title “Fear among Syrians: a Proposed Cutoff Score and Validation of the Arabic Fear of COVID-19 Scale- A National Survey” implies that that the results of this survey could generalised to the whole Syrian nation. This does not seem to be the case as the authors acknowledge that They has used “convenience sampling” – line 244, and the results cannot be generalized. This study, thus, cannot be described as a national survey in the title and in the text.

Author response: We agree with the reviewer and have removed “A National Survey” from the title.

6) the emphasis in the title on a “proposed cut-off point” that is useless is not appropriate.

Author response: We understand the reviewers comment, we would like to keep the title like this. We could change the title to “Fear of COVID-19 among Syrians” if the reviewer prefers this one.

Reviewer #2: I believe that the present study can add merits to the present understanding of fear toward COVID-19. To the best of my knowledge, although many studies have translated and validated the Fear of COVID-19 Scale (FCV-19S), none have proposed a cutoff for the FCV-19S. Therefore, the major contribution of the present study is the proposed cutoff with using previous standardized fear scales. Moreover, the present study has the strengths of (1) rigorous translation for the FCV-19S, (2) large sample size of 3989, and (3) adequate statistical methods. Therefore, I read this paper with greatest interests. However, several points should be addressed before I recommend publication. Please see my comments below.

Author response: We appreciate the reviewer’s compliments and will thoroughly address the comments provided below.

1. I would like the authors to provide more information regarding the psychometric evidence of the FCV-19S. The following references are recommended to be included in a revision.

Chang, K.-C., Hou, W.-L., Pakpour, A. H., Lin, C.-Y., Griffiths, M. D. (accepted). Psychometric testing of three COVID-19-related scales among people with mental illness. International Journal of Mental Health and Addiction.

Pakpour, A. H., Griffiths, M. D., Chang, K.-C., Chen, Y.-P., Kuo, Y.-J., & Lin, C.-Y. (2020). Assessing the fear of COVID-19 among different populations: A response to Ransing et al. (2020). Brain, Behavior, and Immunity, 89, 524-525.

Andrade, E. F., Pereira, L. J., Oliveira, A., Orlando, D. R., Alves, D., Guilarducci, J. S., & Castelo, P. M. (2020). Perceived fear of COVID-19 infection according to sex, age and occupational risk using the Brazilian version of the Fear of COVID-19 Scale. Death studies, 1–10. Advance online publication. https://doi.org/10.1080/07481187.2020.1809786

Haktanir, A., Seki, T., & Dilmaç, B. (2020). Adaptation and evaluation of Turkish version of the fear of COVID-19 Scale. Death studies, 1–9. Advance online publication. https://doi.org/10.1080/07481187.2020.1773026

Caycho-Rodríguez, T., Valencia, P. D., Vilca, L. W., Cervigni, M., Gallegos, M., Martino, P., Barés, I., Calandra, M., Rey Anacona, C. A., López-Calle, C., Moreta-Herrera, R., Chacón-Andrade, E. R., Lobos-Rivera, M. E., Del Carpio, P., Quintero, Y., Robles, E., Panza Lombardo, M., Gamarra Recalde, O., Buschiazzo Figares, A., White, M., … Burgos Videla, C. (2021). Cross-cultural measurement invariance of the fear of COVID-19 scale in seven Latin American countries. Death studies, 1–15. Advance online publication. https://doi.org/10.1080/07481187.2021.1879318

Soares, F. R., Afonso, R. M., Martins, A. P., Pakpour, A. H., & Rosa, C. P. (2021). The fear of the COVID-19 Scale: validation in the Portuguese general population. Death studies, 1–7. Advance online publication. https://doi.org/10.1080/07481187.2021.1889722

Moreta-Herrera, R., López-Calle, C., Caycho-Rodríguez, T., Cabezas Guerra, C., Gallegos, M., Cervigni, M., Martino, P., Barés, I., & Calandra, M. (2021). Is it possible to find a bifactor structure in the Fear of COVID-19 Scale (FCV-19S)? Psychometric evidence in an Ecuadorian sample. Death studies, 1–11. Advance online publication. https://doi.org/10.1080/07481187.2021.1914240

Author response: We agree with the author and have implanted this within the introduction section.

2. In the second paragraph of the Introduction, the authors should include the following references, which also support the statement that COVID-19 impacts on individuals' physical and mental health.

Fung, X. C. C.#, Siu, A., Potenza, M. N., O'Brien, K. S., Latner, J. D., Chen, C.-Y., Chen, I.-H., & Lin, C.-Y. (2021). Problematic use of internet-related activities and perceived weight stigma in schoolchildren: A longitudinal study across different epidemic periods of COVID-19 in China. Frontiers in Psychiatry.

Malik, S., Ullah, I., Irfan, M., Ahorsu, D. K., Lin, C.-Y., Pakpour, A. H., Griffiths, M. D., Rehman, I. U., & Minhas, R. (2021). Fear of COVID-19 and workplace phobia among Pakistani doctors: A survey study. BMC Public Health, 21, 833.

Mahmoudi, H., Saffari, M., Movahedi, M., Sanaeinasab, H., Rashidi-Jahan, H., Pourgholami, M., Poorebrahim, A., Barshan, J., Ghiami, M., Khoshmanesh, S., Potenza, M. N., Lin, C.-Y.*, Pakpour, A. H.* (2021). The mediating role of mental health in associations between COVID-19-related self-stigma, PTSD, quality of life and insomnia among patients recovered from COVID-19. Brain and Behavior, 11, e02138.

Chen, C.-Y., Chen, I.-H., Hou, W.-L., Potenza, M. N., O'Brien, K. S., Lin, C.-Y., & Latner, J. D. (2021). The relationship between children’s problematic Internet-related behaviors and psychological distress during the onset of the COVID-19 pandemic: A longitudinal study. Journal of Addiction Medicine.

Chen, C.-Y., Chen, I.-H., Pakpour, A. H., Lin, C.-Y., & Griffiths, M. D. (2021). Internet-related behaviors and psychological distress among schoolchildren during the COVID-19 school hiatus. Cyberpsychology, Behavior, and Social Networking.

Chen, I.-H., Chen, C.-Y., Pakpour, A. H., Griffiths, M. D., Lin, C.-Y., Li, X.-D., Tsang, H. W. H. (2021). Problematic internet-related behaviors mediate the associations between levels of internet engagement and distress among schoolchildren during COVID-19 lockdown: A longitudinal structural equation modeling study. Journal of Behavioral Addictions, 10(1), 135-148.

Pramukti, I., Strong, C., Sitthimongkol, Y., Setiawan, A., Pandin M. G. R., Yen, C.-F., Lin, C.-Y., Griffiths, M. D., Ko, N.-Y. (2020). Anxiety and suicidal thoughts during the COVID-19 pandemic: A cross-country comparison among Indonesian, Taiwanese, and Thai university students. Journal of Medical Internet Research, 22(12), e24487.

Chen, C.-Y., Chen, I.-H., O'Brien, K. S., Latner, J. D., & Lin, C.-Y. (2021). Psychological distress and internet-related behaviors between schoolchildren with and without overweight during the COVID-19 outbreak. International Journal of Obesity, 45(3), 677-686.

Ahorsu, D. K., Lin, C.-Y., Pakpour, A. H. (2020). The association between health status and insomnia, mental health, and preventive behaviours: The mediating role of fear of COVID-19. Gerontology and Geriatric Medicine, 6, 1-9.

Chang, K.-C., Strong, C., Pakpour, A. H., Griffiths, M. D., & Lin, C.-Y. (2020). Factors related to preventive COVID-19 infection behaviors among people with mental illness. Journal of the Formosan Medical Association, 119(12), 1772-1780.

Lin, C.-Y., Broström, A., Griffiths, M. D., & Pakpour, A. H. (2020). Investigating mediated effects of fear of COVID-19 and COVID-19 misunderstanding in the association between problematic social media use and distress/insomnia. Internet Interventions, 21, 100345.

Chen, I.-H., Chen, C.-Y., Pakpour, A. H., Griffiths, M. D., & Lin, C.-Y. (2020). Internet-related behaviors and psychological distress among schoolchildren during COVID-19 school suspension. Journal of the American Academy of Child and Adolescent Psychiatry, 159(10), 1099-1102.

Lin, C.-Y. (2020). Social reaction toward the 2019 Novel Coronavirus (COVID-19). Social Health & Behavior, 3, 1-2.

Author response: Thank you for providing the citations to further support our statement within the manuscript. These citations have been implemented within the manuscript.

3. The authors said "For this study, we used the Arabic version of FCV-19S, which was validated in a previous study.(31)". However, they also provide a section to describe the translation procedure. This is somewhat confusing because I cannot know whether the authors translated the FCV-19S by themselves or the translation descriptions are derived from the reference #31.

Author response: We apologise the mistake, we did not use the validated Arabic version of FCV-19S. This has been removed from the text.

4. In ethics, please provide the registered number of the IRB.

Author response: The IRB ant SPU ethically approved our study but did grant us a registered number.

5. If possible, I would like to know if there is any demographic difference between the analyzed sample (n=3989) and those who gave a consent but not used for data analysis (n=441). This can provide information to the readers regarding the sample representativeness.

Author response: The 441 participants who did not meet the inclusion criteria were either below 18, residing outside Syria, or uncompleted survey. This is the information we have about those excluded. We added asentence in the results section.

6. In Discussion, the authors should mention that fear may be a factor impacts an individual's protective behaviors, including vaccination uptake using the references I provided below. Therefore, one should have a certain level of fear but not an overwhelming fear.

Wang, P.-W., Ahorsu, D. K., Lin, C.-Y., Chen, I.-H., Yen, C.-F., Kuo, Y.-J., Griffiths, M. D., & Pakpour, A. H. (2021). Motivation to Have COVID-19 Vaccination Explained Using an Extended Protection Motivation Theory Among University Students in China: The Role of Information Sources. Vaccines, 9, 380.

Author response: A very nice point suggested by the reviewer, we have implemented this within the discussion

7. Following my previous comment, the authors can make some comments regarding the low willingness of vaccination uptake in some countries (Kukreti et al., 2021), and thus monitoring fear is important.

Kukreti, S., Lu, M.-L., Lin, Y.-H., Strong, C., Lin, C.-Y., Ko, N.-Y., Chen, P.-L., & Ko, W.-C. (2021). Willingness of Taiwan’s healthcare workers and outpatients to vaccinate against COVID-19 during a period without community outbreaks. Vaccines, 9(3), 246.

Author response: We understand the suggesting provided by the reviewer; however, we would like to avoid deviating from the topic of the paper. If the reviewer insists on adding this point we would be happy to do so.

8. I would encourage the authors reformatted their tables as they are hard to read. Please consult some published articles in PLOS ONE to revise these tables.

Author response: We have read the table formatting information and had a look at a few published studies by the PLOS ONE journal. We hope the tables are in the correct format now.

9. The references are not in good shape. Specifically, the authors used "Organization WH" to indicate "World Health Organization", which is incorrect. Also, there are some repeated references in the list (e.g., #16 and #19 are the same reference). The authors should check their reference list carefully.

Author response: We apologize for this, and have made the necessary amendments.

7 Jul 2021

PONE-D-21-14780R1

Fear among Syrians: a Proposed Cutoff Score and Validation of the Arabic Fear of COVID-19 Scale

PLOS ONE

Dear Dr. Mohsen,

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see:  http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at  https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Ali B. Mahmoud, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have responded to some but not all comments. The calculation of sample size is pointless and could be misleading. The authors agree that the population of Syria at the time of the study was unknown, i.e. it is not possible to calculate the sample size. In addition, sample size is calculated in order to generalise the results, and the results of this study cannot be generalised. I recommend removing the section about sample size.

My comment about the cutoff point stands. A 50/50 cutoff point is pointless. It is mere chance and the questionnaire is adding nothing.

Reviewer #2: The authors have improved their work after considering the comments from both reviewers. However, some minor works are needed further. Specifically, the authors did not reformat their reference list in a good shape. The Organization WH still shows up in the reference list. Please make sure the correctness of the reference list.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Adib Essali

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

7 Jul 2021

Response letter

We would like to thank both the editor and reviewers for spending their valuable time reviewing this manuscript. We have thoroughly assessed the comments and implemented them into our revised manuscript, now that this article has been made suitable, we aspire to have this article published in your journal.

The following letter will report the responses to the reviewers’ comments.

ournal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Author response: We apologize and have edited the references mentioned by the reviewer below. W are not aware of citing papers that have been retracted within the manuscript. If there is any we would appreciate highlighting any out for us to manage appropriately.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

________________________________________

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

________________________________________

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have responded to some but not all comments. The calculation of sample size is pointless and could be misleading. The authors agree that the population of Syria at the time of the study was unknown, i.e. it is not possible to calculate the sample size. In addition, sample size is calculated in order to generalise the results, and the results of this study cannot be generalised. I recommend removing the section about sample size.

My comment about the cutoff point stands. A 50/50 cutoff point is pointless. It is mere chance and the questionnaire is adding nothing.

Author response: We removed the section on calculating sample size.

Reviewer #2: The authors have improved their work after considering the comments from both reviewers. However, some minor works are needed further. Specifically, the authors did not reformat their reference list in a good shape. The Organization WH still shows up in the reference list. Please make sure the correctness of the reference list.

Author response: We have changed the reference of Organization WH to WHO.

11 Jul 2021

PONE-D-21-14780R2

Fear among Syrians: a Proposed Cutoff Score and Validation of the Arabic Fear of COVID-19 Scale

PLOS ONE

Dear Dr. Mohsen,

Thank you for submitting your manuscript to PLOS ONE.

The reviewers have now recommended publication. However, before proceeding with accepting your paper for publication in PLOS ONE, I identify a few minor improvements that would benefit the quality of your research. Therefore, I invite you to submit a revised version of the manuscript that addresses the following points alongside a response file showing how you have responded to each of my comments.

Please report the average variance extracted (AVE) scores and items’ outer loadings as an assessment of construct validity for all of the measures used in the study. Also, computing the composite reliability (CR) would be great.

The script does not describe how the discriminant validity was assessed (e.g., HTMT). Please, revise accordingly.

Given the ongoing turmoil in Syria, literature on “Wartime Crisis Perceptions” should be brought up in the discussion, mainly concerning not considering this variable in the study, hence offering directions for future research. Similarly, COVID-19 perception (defined as “as the perceived probability of discomfort and/or worry, during COVID-19 pandemic, concerning the pandemic adverse health, economic and social ramifications articulated as disruptions to the people’s pre-pandemic everyday life – lead to redefining of the everyday life to the new normal.”) which conceptually should occur before developing fears and other negative experiences is warranted a discussion here too.

Ensure the accuracy of terms used in the paper (e.g., anxiety, fear are emotions that our perception of events would trigger).

The whole manuscript would benefit from proper proofreading.

I found some similarity issues that you will need to remedy. Please, see attached the similarity check report and paraphrase/cite accordingly.

Finally, given the study context, an Arabic abstract of the research, as supplementary material, would add more visibility to your paper. Also, ensure a list of the translated items is offered in Arabic as supplementary material too.

Please submit your revised manuscript by Aug 25 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see:  http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at  https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Ali B. Mahmoud, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for making the changes. I hope that this will be the beginning of a successful research career. Please remember that panning and written a protocol BEFORE conducting research in the most important point in this field. Seek advice and discuss your protocol with many people before conducting studies in the future. With my best wishes.

Reviewer #2: The authors have revised the manuscript again and I have no more comments now. I am satisfied with the current version.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Adib Essali

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: PONE-D-21-14780R2.pdf

Click here for additional data file.

22 Sep 2021

Response letter

We would like to thank both the editor and reviewers for spending their valuable time reviewing this manuscript. We have thoroughly assessed the comments and implemented them into our revised manuscript, now that this article has been made suitable, we aspire to have this article published in your journal.

The following letter will report the responses to the reviewers’ comments.

We've checked your submission and before we can proceed, we need you to address the following issues:

Author response: We will address the following issue provided.

2.Please include a separate legend for each figure in your manuscript.

Author response: We have included figure captions in the manuscript text in read order, immediately following the paragraph where the figure is first cited.

Submitted filename: Response Letter #4.docx

Click here for additional data file.

24 Sep 2021

5 Feb 2022

Response letter

We would like to thank both the editor and reviewers for spending their valuable time reviewing this manuscript. We have thoroughly assessed the comments and implemented them into our revised manuscript, now that this article has been made suitable, we aspire to have this article published in your journal.

The following letter will report the responses to the reviewers’ comments.

1. Please report the average variance extracted (AVE) scores and items’ outer loadings as an assessment of construct validity for all of the measures used in the study. Also, computing the composite reliability (CR) would be great.

Author response: We have added a table that includes factor loading, corrected item total correlation, cronbach’s alpha, inter item correlation range, skewness, kurtosis, and Kaiser meyer-olkin for each item of the FCV-19S. The data is presented in table 3. We also calculated the AVE and CR and reported them in the results section.

2. The script does not describe how the discriminant validity was assessed (e.g., HTMT). Please, revise accordingly.

Author response: We have reported the discriminant validity.

3. Given the ongoing turmoil in Syria, literature on “Wartime Crisis Perceptions” should be brought up in the discussion, mainly concerning not considering this variable in the study, hence offering directions for future research. Similarly, COVID-19 perception (defined as “as the perceived probability of discomfort and/or worry, during COVID-19 pandemic, concerning the pandemic adverse health, economic and social ramifications articulated as disruptions to the people’s pre-pandemic everyday life – lead to redefining of the everyday life to the new normal.”) which conceptually should occur before developing fears and other negative experiences is warranted a discussion here too.

Author response: A very important point, we have included this point in the limitations section. Highlighting the need for this point to be further assessed.

4. Ensure the accuracy of terms used in the paper (e.g., anxiety, fear are emotions that our perception of events would trigger).

Author response: We have revised the manuscript for the point mentioned above.

5. The whole manuscript would benefit from proper proofreading.

Author response: We have revised the manuscript.

6. I found some similarity issues that you will need to remedy. Please, see attached the similarity check report and paraphrase/cite accordingly.

Author response: We have rephrased as many sentences as we could from the file sent. However, there are many phrases and words we cannot change, for example “fear of COVID-19 scale” we noticed these were picked up. Also, places we can not change include the affiliation section. We hope the manuscript is better now.

7. Finally, given the study context, an Arabic abstract of the research, as supplementary material, would add more visibility to your paper. Also, ensure a list of the translated items is offered in Arabic as supplementary material too.

Author response: We have translated the abstract into Arabic and have attached it as a supplementary file. The items have been translated into Arabic and are available in the supplementary material as S3.

Submitted filename: Response Letter #5.docx

Click here for additional data file.

8 Feb 2022

Fear among Syrians: a Proposed Cutoff Score for the Arabic Fear of COVID-19 Scale

PONE-D-21-14780R4

Dear Dr. Mohsen,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Ali B. Mahmoud, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

4 Mar 2022

PONE-D-21-14780R4

Fear among Syrians: a Proposed Cutoff Score for the Arabic Fear of COVID-19 Scale

Dear Dr. Mohsen:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Ali B. Mahmoud

Academic Editor

PLOS ONE