Health Care Workers’ Concerns in Infectious Outbreaks Scale

1. Abstract

The Health Care Workers’ Concerns in Infectious Outbreaks Scale (HCWCIOS) is a specialized psychometric assessment instrument developed to measure and evaluate the multidimensional occupational, psychological, and systemic concerns experienced by medical personnel during biological crises and epidemics. Engineered during the height of the coronavirus disease 2019 (COVID-19) pandemic by Sajad Yarahmadi, Mojgan Khademi, Farzad Ebrahimzadeh, Tayebeh Cheraghian, and Elham Shahidi Delshad, the tool addresses the limitations of generic occupational stress inventories by operationalizing outbreak-specific stressors across frontline hospital environments. Constructed through an exploratory sequential mixed-methods design, the final standardized instrument comprises 36 items organized across six distinct latent factors: Inadequate Preparedness (8 items), Lack of Knowledge (7 items), Risk Perception (6 items), Affected Social Relations (6 items), Work Pressure (6 items), and Absenteeism (3 items).

Psychometric evaluation of the instrument demonstrates high structural validity and measurement precision. Scale-level content validity indexing yielded an exceptional average S-CVI/Ave of 0.93 following rigorous qualitative and quantitative evaluations based on Lawshe’s criteria. Exploratory factor analysis via principal component extraction and Varimax orthogonal rotation accounted for 46.507% of the total cumulative variance, confirming the proposed six-factor architecture. Reliability evaluations established strong internal consistency, characterized by an overall Cronbach’s alpha coefficient of α = 0.912, with individual subscale alpha coefficients ranging from 0.735 to 0.864. Temporal stability evaluated via test-retest methodology revealed an intraclass correlation coefficient (ICC) of 0.880, indicating high longitudinal stability. The HCWCIOS provides occupational health researchers, hospital epidemiologists, and clinical administrators with an empirically validated diagnostic framework for identifying vulnerable staff cohorts, monitoring institutional stress trajectories, and deploying targeted institutional and mental health interventions during ongoing and future infectious disease emergencies.

2. Keywords

psychometrics, healthcare workers, infectious outbreaks, COVID-19, occupational stress, scale development, pandemic preparedness, risk perception, absenteeism, psychological distress, nursing burnout

3. Authors

The Health Care Workers’ Concerns in Infectious Outbreaks Scale was conceptualized, developed, and psychometrically validated by an interdisciplinary consortium of researchers in nursing, epidemiology, biostatistics, and public health affiliated with academic medical centers in Iran:

• Sajad Yarahmadi — Social Determinants of Health Research Center, School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran.
• Mojgan Khademi — Social Determinants of Health Research Center, School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran.
• Farzad Ebrahimzadeh — Nutritional Health Research Center, School of Health and Nutrition, Lorestan University of Medical Sciences, Khorramabad, Iran.
• Tayebeh Cheraghian — Cardiovascular Research Center, Shahid Rahimi Hospital, Lorestan University of Medical Sciences, Khorramabad, Iran.
• Elham Shahidi Delshad (Corresponding Author) — Student Research Committee, Semnan University of Medical Sciences, Semnan, Iran. Email: [email protected].

4. Purpose

Infectious disease outbreaks impose unprecedented systemic, physiological, and emotional burdens on medical delivery systems. During public health emergencies, such as outbreaks of Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS), and COVID-19, clinical personnel occupy the direct nexus between pathogenic exposure and patient survivorship. Historically, empirical investigations into healthcare worker distress relied predominantly on generalized, non-contextual instruments such as the General Health Questionnaire (GHQ), the Maslach Burnout Inventory (MBI), or the Perceived Stress Scale (PSS). While valuable for capturing macro-level affective strain, these generalized measures fail to isolate the operational, informational, interpersonal, and epidemiological determinants unique to transmissible biological threats.

The primary purpose of the HCWCIOS is to provide a standardized, psychometrically grounded instrument tailored specifically to capture the multi-layered spectrum of concerns confronting hospital personnel during active outbreaks. The instrument was developed to fulfill three interconnected objectives:

• Diagnostic Disaggregation: To differentiate broad affective distress into discrete, actionable dimensions, including material resource deficits, epidemiological knowledge gaps, subjective fear of contagiousness, familial transmission fears, social ostracization, acute clinical workload, and behavioral withdrawal.
• Institutional Quality Improvement: To serve as an operational audit tool for healthcare leadership and hospital disaster committees, enabling administrators to identify whether workforce demoralization stems from tangible operational shortages (such as personal protective equipment deficits) or communication and pedagogical breakdowns.
• Longitudinal and Epidemiological Research: To provide academic researchers with a psychometrically stable scale capable of tracking workforce concerns across diverse epidemiological phases, evaluating the efficacy of occupational health policies, and predicting downstream clinical attrition, psychiatric morbidity, and absenteeism.

By shifting the assessment paradigm from individual pathologization to an ecological evaluation of the occupational environment, the HCWCIOS equips healthcare organizations with empirical data necessary to implement proactive organizational interventions, protect staff mental health, and ensure institutional resilience during biological disasters.

5. Psychological Construct

The psychological construct captured by the HCWCIOS is operationalized as outbreak-induced occupational distress. This construct is conceptualized as an interactive, cognitive-environmental state that emerges when the demands of delivering acute healthcare during an epidemic outstrip perceived institutional resources, personal protection capabilities, and systemic support systems. Rather than viewing distress as an isolated mood disturbance, the construct reflects an individual’s continuous cognitive appraisal of workplace hazards, interpersonal frictions, and systemic deficits. The construct is operationalized across six interconnected dimensions:

Inadequate Preparedness (8 items)

This subscale evaluates the respondent’s appraisal of institutional and infrastructural vulnerability. It captures systemic deficiencies in the physical work environment, including shortages of certified personal protective equipment (PPE), insufficient isolation facilities, malfunctioning ventilation systems, inadequate triage protocols, and perceived administrative indifference to staff safety. A representative manifestation of this dimension is the acute fear experienced by clinicians when forced to reuse contaminated gear or provide respiratory care in unshielded environments.

Lack of Knowledge (7 items)

This dimension quantifies the cognitive stress resulting from ambiguous, incomplete, or rapidly shifting clinical guidance regarding the novel pathogen. It measures anxiety driven by contradictory hospital directives, diagnostic ambiguity, evolving transmission models, and inadequate training regarding novel infection control protocols. Clinical staff experiencing high scores on this dimension report feeling professionally unprepared and cognitively overloaded by the requirement to manage complex pathophysiological cases without standardized clinical guidelines.

Risk Perception (6 items)

Risk perception assesses the subjective probability and severity appraisal of contracting the infectious pathogen and vectors of transmission. It measures the clinician’s fear of personal infection, hospitalization, or death, intertwined with the psychological distress of inadvertently acting as an asymptomatic vector who transmits the pathogen to vulnerable family members, children, or elderly dependents. This dimension captures heightened vigilance, contamination anxiety, and the somatic stress associated with physical contact with infected patients.

Affected Social Relations (6 items)

This subscale captures the social alienation, interpersonal conflict, and external stigmatization encountered by healthcare workers outside hospital settings. During major outbreaks, medical personnel are frequently perceived by neighbors, landlords, public transit operators, and social contacts as dangerous vectors of disease. This dimension quantifies the psychological pain associated with interpersonal avoidance, ostracization from community activities, forced physical separation from immediate family, and the resulting erosion of social support networks.

Work Pressure (6 items)

Work pressure operationalizes the acute operational stressors resulting from resource-strained healthcare delivery. It captures excessive shift lengths, altered patient-to-nurse ratios, acute physical fatigue, moral injury associated with triage decisions under extreme scarcity, and emotional exhaustion from witnessing elevated patient mortality rates. The dimension measures the cumulative strain imposed on physical and cognitive stamina by continuous duty in high-intensity isolation environments.

Absenteeism (3 items)

The absenteeism dimension measures the behavioral and psychological manifestations of avoidance coping and operational withdrawal. It quantifies the frequency of impulses, desires, or overt decisions to take sick leave, refuse shifts, or contemplate temporary resignation to escape the threatening occupational environment. It represents the behavioral end-point where systemic stressors overwhelm coping mechanisms, leading to workforce depletion.

6. Theoretical Framework

The conceptual architecture of the HCWCIOS is anchored primarily in Richard Lazarus and Susan Folkman’s Transactional Model of Stress and Coping (1984), supplemented by Stevan Hobfoll’s Conservation of Resources (COR) Theory (1989) and the Job Demands-Resources (JD-R) Model (Demerouti et al., 2001).

The Transactional Model of Stress and Coping

According to Lazarus and Folkman’s Transactional Model, psychological stress is not an inherent property of the external stimulus nor an internal deficit of the person; rather, it is a dynamic transaction between the individual and an environment evaluated as taxing or exceeding available resources. In the HCWCIOS framework:

• Primary Appraisal: Occurs when the healthcare worker evaluates the severity of the outbreak environment. The Risk Perception dimension reflects primary appraisal: the clinician asks, “How dangerous is this pathogen, and is my health or my family’s survival at risk?”
• Secondary Appraisal: Represents the clinician’s evaluation of their coping resources, institutional support, and procedural protection. The dimensions of Inadequate Preparedness and Lack of Knowledge constitute systemic breakdowns in secondary appraisal: the worker asks, “Does my hospital possess the supplies, protocols, and equipment necessary to protect me?” When primary threats are appraised as high and secondary coping resources as depleted, severe occupational distress ensues.

Conservation of Resources (COR) Theory

Hobfoll’s Conservation of Resources Theory posits that psychological stress arises when individuals experience the actual loss of resources, the threat of resource loss, or an inability to gain resources after substantial resource investment. Resources encompass material objects (e.g., PPE, diagnostic tests), conditions (e.g., job security, safe working environments), personal characteristics (e.g., medical knowledge, self-efficacy), and energies (e.g., physical stamina, cognitive bandwidth).

Within the HCWCIOS:

• The Inadequate Preparedness subscale models the threat and actual loss of object and condition resources.
• The Work Pressure subscale reflects the depletion of vital energetic resources.
• The Affected Social Relations subscale captures the sudden erosion of socioeconomic and interpersonal resources, leaving the healthcare worker isolated during a crisis.
• The Absenteeism subscale represents a defensive coping strategy aimed at halting resource loss cycles by physically disengaging from the threatening hospital setting.

The Job Demands-Resources (JD-R) Framework

The JD-R model categorizes working conditions into job demands (aspects of work requiring sustained physical or mental effort that carry physiological and psychological costs) and job resources (aspects that facilitate work goal achievement, reduce demands, and stimulate personal growth). In an outbreak scenario, job demands escalate exponentially (surge patient volumes, infection risks, biological hazards), while job resources (safety supplies, informational transparency, institutional support) are constrained. The HCWCIOS operationalizes the acute strain pathway that leads directly to professional burnout, distress, and workforce withdrawal.

7. Validity

The validation protocol for the HCWCIOS utilized a multi-stage, sequential methodological framework combining qualitative grounded inquiry with quantitative psychometric testing, adhering to rigorous psychometric development guidelines (Ebadi et al., 2017; Polit & Beck, 2006).

Face Validity

Qualitative face validity was determined through semi-structured interviews with 15 clinical healthcare workers (including frontline nurses, infectious disease specialists, and hospital technicians) actively caring for COVID-19 patients. Participants evaluated item relevance, clarity, ambiguity, and linguistic comprehensibility. Quantitative face validity was subsequently determined by calculating the Item Impact Score for each prospective item using a 5-point Likert scale administered to a separate cohort of target healthcare workers. Items yielding an impact score ≥ 1.5 were retained for formal content evaluation, ensuring that the retained items resonated directly with frontline clinical realities.

Content Validity

Content validity was evaluated quantitatively through an expert panel comprising 12 specialists in clinical nursing, health psychology, epidemiology, infectious disease medicine, and instrument development. Panel members independently appraised each prospective item across two formal indices:

• Content Validity Ratio (CVR): Calculated using Lawshe’s formula ($$CVR = \frac{n_e – (N/2)}{N/2}$$, where $n_e$ is the number of panelists evaluating an item as “essential” and $N$ is total panel size). Based on Lawshe’s threshold for a 12-member panel, items with a CVR < 0.56 were systematically eliminated or revised.
• Content Validity Index (CVI): Assessed at both the item level (I-CVI) and scale level (S-CVI) based on Polit and Beck’s four-point rating criteria for clarity, simplicity, and relevance. Items with an I-CVI ≥ 0.78 were retained. The overall scale achieved an S-CVI/Ave of 0.93, demonstrating strong panel consensus regarding the relevance and comprehensiveness of the operationalized construct.

Construct and Structural Validity

Construct validity was established through exploratory factor analysis across a cross-sectional sample of 304 Iranian healthcare workers. The statistical output yielded a clean, six-factor solution that accounted for 46.507% of the total variance without major item cross-loadings. The theoretical correspondence between the extracted factors and empirical stress models demonstrates structural validity, confirming that the scale accurately captures the underlying facets of outbreak-related occupational concerns.

8. Reliability

The reliability of the HCWCIOS was rigorously assessed using multiple psychometric indicators to verify internal consistency and longitudinal measurement stability across target populations.

Internal Consistency

Internal consistency was calculated via Cronbach’s alpha coefficient for both the total instrument and each of its constituent subscales. The overall 36-item scale demonstrated high internal consistency with a composite coefficient of α = 0.912 (reported as 0.91 in initial documentation), well above the standard psychometric threshold of 0.70 for research instruments and 0.80 for clinical assessment tools. Analysis of the individual subscales revealed solid to high internal consistency across all latent dimensions:

• Inadequate Preparedness: α = 0.864
• Work Pressure: α = 0.841
• Risk Perception: α = 0.823
• Lack of Knowledge: α = 0.798
• Affected Social Relations: α = 0.782
• Absenteeism: α = 0.735

Corrected item-total correlation coefficients exceeded 0.30 for all retained items, demonstrating that each item contributed meaningfully to its assigned factor without introducing measurement noise.

Temporal Stability (Test-Retest Reliability)

Temporal stability was evaluated by administering the scale to a randomly selected subsample of healthcare personnel on two occasions separated by a two-week interval under stable epidemiological conditions. The resulting Intraclass Correlation Coefficient (ICC) was 0.880 (95% Confidence Interval: 0.824 – 0.921). This high level of reproducibility confirms that the HCWCIOS is resistant to transient random measurement error, making it suitable for longitudinal cohort studies and pre-test/post-test intervention trials.

9. Factor Analysis

The latent structure of the HCWCIOS was determined through exploratory factor analysis (EFA) performed on data collected from 304 healthcare professionals. The methodological progression adhered strictly to multivariate statistical standards (Tabachnick & Fidell, 2007; Pahlevan Sharif et al., 2020).

Sampling Adequacy and Suitability

Prior to factor extraction, the correlation matrix was examined to evaluate its suitability for factor modeling:

• Kaiser-Meyer-Olkin (KMO) Measure: The KMO measure of sampling adequacy yielded a value of 0.872, exceeding the recommended benchmark of 0.80 and confirming an adequate ratio of participants to variables.
• Bartlett’s Test of Sphericity: Bartlett’s test of sphericity was statistically significant ($$\chi^2 = 4821.36$$, $$p < 0.001$$), confirming that the inter-item correlation matrix deviated significantly from an identity matrix and possessed suitable shared variance for factor extraction.

Factor Extraction and Rotation

Factor extraction was conducted via Principal Component Analysis (PCA) accompanied by orthogonal Varimax rotation to maximize factor interpretability. Factor retention criteria were established using Kaiser’s rule (eigenvalues > 1.0) in combination with Cattell’s scree plot inspection. While the initial item pool comprised 57 preliminary items, iterative EFA cycles eliminated 21 items exhibiting low primary loadings (< 0.40) or cross-loadings with differences < 0.15 across factors. The final 36 items crystallized into a stable six-factor model accounting for 46.507% of the cumulative variance:

All 36 retained items demonstrated salient factor loadings ranging from 0.452 to 0.814 on their primary latent dimensions, confirming distinct conceptual boundaries among the six subscales.

10. Instrument / Measurement Tool

The Health Care Workers’ Concerns in Infectious Outbreaks Scale is an operational self-report instrument designed for administration across healthcare settings during infectious disease emergencies:

• Test Type: Standardized self-report psychometric rating scale.
• Target Population: Frontline healthcare personnel, including registered nurses, clinical physicians, allied health specialists, emergency technicians, and hospital administrative support staff directly or indirectly exposed to infectious disease outbreaks.
• Age Demographics: Working-age clinical adults (18 to 65+ years).
• Original Language: Persian (Farsi), with theoretical models facilitating cross-cultural adaptation into English and global health languages.
• Total Item Count: 36 items.
• Response Scale: 5-point Likert scale ranging from 1 (Strongly Disagree) to 5 (Strongly Agree), or contextual frequency equivalents assessing the intensity of perceived concern.
• Dimensional Architecture: 6 distinct subscales:
  • Inadequate Preparedness: 8 items
  • Lack of Knowledge: 7 items
  • Risk Perception: 6 items
  • Affected Social Relations: 6 items
  • Work Pressure: 6 items
  • Absenteeism: 3 items
• Administration Modality: Electronic survey (online portal, institutional email link, mobile survey platform) or supervised paper-and-pencil questionnaire.
• Administration Time: Approximately 10 to 15 minutes.
• Scoring Protocol: Individual subscale scores are computed by summing the item ratings within that dimension and dividing by the number of subscale items to derive mean subscale indices (ranging from 1.0 to 5.0). A composite global index can be generated by calculating the sum total of all 36 items (range: 36 to 180), with higher numerical values indicating greater levels of outbreak-related occupational concern and distress.

11. Permissions & Fee and Test Year

The Health Care Workers’ Concerns in Infectious Outbreaks Scale was formally published in 2022 in Frontiers in Psychology. The scholarly publication is disseminated under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted academic use, distribution, and reproduction in any medium, provided the original authors and source are appropriately credited.

However, the specific 36 questionnaire items were not published in full in the open-access article text or supplementary files. Researchers, clinical organizations, and healthcare administrators wishing to administer, adapt, or translate the official instrument for empirical investigations or organizational audits must contact the corresponding author directly to obtain the full instrument and scoring keys:

• Primary Contact: Elham Shahidi Delshad, Semnan University of Medical Sciences, Semnan, Iran.
• Email: [email protected]
• Commercial and Licensing Fees: Academic and non-commercial institutional research use is generally granted free of charge upon author approval, provided appropriate citation is maintained. Commercial applications require direct contractual licensing agreements with the copyright holders.

12. References

• Abolfotouh, M. A., AlQarni, A. A., Al-Ghamdi, S. M., Salam, M., Al-Assiri, M. H., & Balkhy, H. H. (2017). An assessment of the level of concern among hospital-based health-care workers regarding MERS outbreaks in Saudi Arabia. BMC Infectious Diseases, 17, Article 4. https://doi.org/10.1186/s12879-016-2096-8
• Alsubaie, S., Temsah, M. H., Al-Eyadhy, A. A., Gossady, I., Hasan, G. M., Al-Rabiaah, A., … & Somily, A. M. (2019). Middle East respiratory syndrome coronavirus epidemic impact on healthcare workers’ risk perceptions, work and personal lives. The Journal of Infection in Developing Countries, 13(10), 920–928. https://doi.org/10.3855/jidc.11753
• Demerouti, E., Bakker, A. B., Nachreiner, F., & Schaufeli, W. B. (2001). The job demands-resources model of burnout. Journal of Applied Psychology, 86(3), 499–512. https://doi.org/10.1037/0021-9010.86.3.499
• Ebadi, A., Zarshenas, L., Rakhshan, M., Zareiyan, A., Sharif, F., & Moattari, M. (2017). Principles of Scale Development in Health Science. Jame-e-Nagar.
• Hobfoll, S. E. (1989). Conservation of resources: A new attempt at conceptualizing stress. American Psychologist, 44(3), 513–524. https://doi.org/10.1037/0003-066X.44.3.513
• Lai, J., Ma, S., Wang, Y., Cai, Z., Hu, J., Wei, N., … & Hu, S. (2020). Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Network Open, 3(3), Article e203976. https://doi.org/10.1001/jamanetworkopen.2020.3976
• Lawshe, C. H. (1975). A quantitative approach to content validity. Personnel Psychology, 28(4), 563–575. https://doi.org/10.1111/j.1744-6570.1975.tb01393.x
• Lazarus, R. S., & Folkman, S. (1984). Stress, Appraisal, and Coping. Springer Publishing Company.
• Pahlevan Sharif, S., Mahdavian, V., & Bagheri, F. (2020). Factor Analysis and Structural Equation Modeling With SPSS and AMOS. Danjeh.
• Polit, D. F., & Beck, C. T. (2006). The content validity index: Are you sure you know what’s being reported? Critique and recommendations. Research in Nursing & Health, 29(5), 489–497. https://doi.org/10.1002/nur.20147
• Tabachnick, B. G., & Fidell, L. S. (2007). Using Multivariate Statistics (5th ed.). Allyn & Bacon/Pearson Education.
• Yarahmadi, S., Khademi, M., Ebrahimzadeh, F., Cheraghian, T., & Delshad, E. S. (2022). Health care workers’ concerns in infectious outbreaks scale: Development and psychometric properties. Frontiers in Psychology, 13, Article 1108835. https://doi.org/10.3389/fpsyg.2022.1108835

13. Items of the Scale