Journal of Loss and Trauma

International Perspectives on Stress & Coping

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/upil20

Measuring COVID-19 Stressors and Their Impact:

The Second-Order Factor Model and Its Four First-
Order Factors: Infection Fears, Economic, Grief,
and Lockdown Stressors

Ibrahim A. Kira, Hanaa A.M Shuwiekh, Jeffrey S. Ashby, Kenneth G. Rice &
Amthal Alhuwailah

To cite this article: Ibrahim A. Kira, Hanaa A.M Shuwiekh, Jeffrey S. Ashby, Kenneth G. Rice &
Amthal Alhuwailah (2021): Measuring COVID-19 Stressors and Their Impact: The Second-Order
Factor Model and Its Four First-Order Factors: Infection Fears, Economic, Grief, and Lockdown
Stressors, Journal of Loss and Trauma, DOI: 10.1080/15325024.2021.1920270

To link to this article: https://doi.org/10.1080/15325024.2021.1920270

Published online: 07 May 2021.

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JOURNAL OF LOSS AND TRAUMA
https://doi.org/10.1080/15325024.2021.1920270

Measuring COVID-19 Stressors and Their Impact: The

Second-Order Factor Model and Its Four First-Order
Factors: Infection Fears, Economic, Grief, and
Lockdown Stressors
Ibrahim A. Kiraa,b, Hanaa A.M Shuwiekhc, Jeffrey S. Ashbyb, Kenneth G. Riceb,
and Amthal Alhuwailahd
a
Center for Cumulative Trauma Studies, and affiliate of Center for Stress, Trauma and Resiliency,
Georgia State University, Atlanta, Georgia, USA; bCenter for Stress, Trauma and Resiliency,
Georgia State University, Atlanta, GA, USA; cPsychology Department, Fayoum University, Fayoum,
Egypt; dDepartment of Psychology, Kuwait University, Kuwait, Kuwait

ABSTRACT ARTICLE HISTORY

The current research aims to test the new measurement Received 12 March 2021
model of COVID-19 stressors which includes four stressor Accepted 18 April 2021
types: infection fears, lockdown, economic, and grief in one
KEYWORDS
second-order factor. Using a sample of 2732 from 11 Arab
COVID-19 stressors; PTSD;
countries and measures for COVID-19 stressors, PTSD, depres- depression; anxiety;
sion, anxiety, and executive function, we conducted explora- executive functions deficits
tory and confirmatory factor analyses, multigroup invariance,
and correlations. A second-order factor with four first-order
factors model fit the data well. All factors were significantly
correlated with PTSD, depression, anxiety, working memory,
and inhibition deficits. The measure and its four subscales
have robust psychometrics and were invariant across genders.

An explosion of research on COVID-19’s impact on mental health was a

natural reaction from the scientific community to the extreme challenges
posed by the continuous and prolonged stressors related to the pandemic
(e.g., Kambhampati et al., 2020). However, this research is only as good as
the sound definitions of COVID-19 stressors and their measurement, as
they are the primary independent variables in COVID-19 mental health
research. Conceptual clarity in the definitions of COVID-19 stressors and
measurement strategy is missing in much of the published research. Some
studies have combined the stressors related to the actual infection of
COVID-19 with those non-related to actual infection. Other studies have
combined COVID-19 stressors with the distress or the stressors’ outcome
in their measurement strategy.

CONTACT Ibrahim A. Kira kiraaref@aol.com Center for Cumulative Trauma Studies, 4906 Woodhurst Way,
Stone Mountain, GA30088, USA.
ß 2021 Taylor & Francis Group, LLC
2 I. A. KIRA ET AL.

Most of the recently published COVID-19 related research has focused

on the impact of one type or the other of COVID-19 stressors. For
instance, a great effort has been placed on measuring the fear of infection
and perceived risk stressors, and related distress/anxiety (Ahorsu et al.,
2020; Arpaci et al., 2020; Lee,2020; Nik
cevic, & Spada, 2020; Taylor et al.,
2020). There are also a plethora of studies that have focused on measuring
the impact of lockdown without measuring lockdown as an independent
variable (e.g., Bland et al., 2021; Di Domenico et al., 2020; Lyons & Brewer,
2021, for review of the evidence of lockdown impact, see Brooks et al.,
2020). Another set of studies focused on the pandemic’s impact on loss of
life and related prolonged grief (e.g., Bertuccio, & Runion, 2020; Eisma
et al., 2020; Eisma et al.,2021; Lee & Neimeyer, 2020; Mayland et al., 2020).
Additionally, many studies have tried to gauge the impact of the pandemic-
related economic stressors and their effect on mental health and socio-eco-
nomic hierarchies (e.g., Bazzoli et al., 2021; Farmer et al., 2020; Kira
et al., 2020).
Most COVID-related studies have not used a comprehensive measure-
ment strategy of the global impact of COVID19 stressors on mental health
and cognitive functioning. While numerous studies have documented the
severe impact of COVID-19 on PTSD, depression, and anxiety, and other
mental health conditions in the general population, health care workers
and professionals, and in COVID-19 patients (for different meta-analyses,
see Al Falasi et al., 2021; Arora et al., 2020; Cenat et al., 2021; Cooke et al.,
2020; de Pablo et al., 2020; Henssler et al., 2020; Krishnamoorthy
et al., 2020; Luo et al., 2020; Pappa et al., 2020; Salari et al., 2020; Salehi
et al., 2021; Santabarbara et al., 2021; Wu et al., 2021; Xiong et al., 2020;
Yuan et al., 2021), studies evaluating the potential impact on cognition are
rare. One recent study did find f that COVID-19 traumatic stressors signifi-
cantly impact increased working memory and inhibition deficits (Kira
et al., 2021).
Kira et al. (2020) attempted to develop a comprehensive multidimen-
sional measure for COVID-19 stressors that included three types of stres-
sors: infection fears, lockdown, and economic stressors. The measure was
translated into several languages, including Turkish, Indonesian, and South
Korean. However, the measure did not include one important COVID-19
stressor, the grief that a significant number had to endure upon losing a
loved one to COVID-19. One important question is about the degree of
relatedness of COVID-19 stressors. Do these proposed four-dimensional
stressors (infection fears, lockdown, economic, and grief stressors) belong
to a common factor that ties them together, or are they separate and unre-
lated, which seems assumed in much of the research on COVID-19. These
questions highlight the importance of developing and validating a robust
 JOURNAL OF LOSS AND TRAUMA 3

measurement strategy for COVID-19 stressors for accurate measurement of

the COVID-19 impact on mental health and cognitive functioning.
The current research aims to test the new measurement model of
COVID-19 stressors (that includes the four types of stressors: fears of infec-
tion, lockdown, economic and grief stressors) structural and Criterion/pre-
dictive validity using a sample from Arab countries. Further, the study
aims to test if these four types of COVID-19 stressors are related to a one-
second order factor. Additionally, we will test the measure and its sub-
scales’ internal consistency and their stability/invariance between males and
females. It is important to note that the rates of the mental health impact
of COVID-19 stressors and actual infection in Arab countries vary
(Alwahaibi et al., 2020). This variation is mainly related to population
density, economic situation, age, and employment factors (Shuwiekh et al.,
2020), with high density and less affluent countries suffered the most.
However, most Arab countries applied strong lockdown policies with strict
enforcement that negatively affected economic activities and employment
rates (e.g., Alfawaz et al., 2021; Cheikh Ismail et al., 2021).

Hypotheses
Hypothesis 1: TheCOVID-19 traumatic stressors scale developed in this study to
measure four types of stressors (infection fears, lockdown, economic, and grief
stressors subscales) is structurally valid as evidenced by the results of exploratory and
confirmatory factor analyses.
Hypothesis 2: The four- types of stressors measured will be related to a single
second-order factor indicating that COVID-19 stressors, while distinct, are related to
a single second-order factor.
Hypothesis 3: The measurement model of the COVID-19 stressors structure will be
stable and invariant across genders.
Hypothesis 4: The COVID-19 traumatic stressors scale and its subscales (infection
fears, lockdown, economic, and grief stressors subscales) will have good Criterion
and predictive validity as evidenced by significant correlations with measures of
PTSD, depression, anxiety, working memory, and inhibition deficits.

Methods
Participants
The sample included N ¼ 2732 adults from 11 Arab countries (Algeria,
Iraq, Jordan, Kuwait, Lebanon, Libya, Palestinian, Saudi Arabia, Sudan,
UAE, and Egypt). Table 1 includes the sample demographic characteristics.
4 I. A. KIRA ET AL.

Table 1. Demographics of the main sample and the two subsamples.

The main A subsample (1) A subsample (2)
Variable Sample (N ¼ 2732) N ¼ 1360 N ¼ 1372
Age Age ranged from 18 to Age ranged between 18 age ranged from 18-91
91, Mean ¼ 26.92, SD and 91 (M ¼ 26.82,SD (M ¼ 26.83,SD
¼ 10.01 ¼ 10.00) ¼ 10.00),
Gender 69.3% Females 67.8% Females 67.9% Females
Religion 97.3% of Muslims and 97.9% of Muslims and 98% of Muslims and 1.5%
1.4% Christians, .3% 1.5% Christians, .3% Christians, .3% Jewish,
Jewish, 1% other Jewish, .3% other . .3% other
Education 1.4% reading and writing 1% reading and writing 1% reading and writing
level, 8.7% high school level, 9.8% high school level, 9.8% middle to
level, 81.6% college level, 81.9% college high school level,
level, and 8.3% level, and 7.3% 81.9% college level,
graduate studies level graduate studies level and 7.3% graduate
studies level
Marital Status 63.2 % single 31.% 65.6% single 29.1% 65.6% single 29.1%
married, 3.2% married, .07% married, .07%
widowed, widowed, .3.2% widowed, .3.2%
0.9% divorced. divorced, 1.4% other . divorced, 1.4% other
Employment 27.2% work with the 27% work with the 27.9% work with the
government , 58.1% government , 44.7% government, 44.8%
Students, 6.2% private Students, 13.1% Students, 12.4%
business, 2.2% retired, private business, 10.7% private business, 11.7%
and 5.8% unemployed retired, and retired, and
3.9% unemployed 3.2% unemployed.
Socio-Economic-Status .7% very low, 1.2% low, .6% very low, 1.4% low, .6% very low, 1.5% low,
81.3% in the middle, 81.6% in the middle, 81.6% in the middle,
14.5% high, 2.3% 14.1% high, 2.3% 14.1% high, 2.2%
very high very high very high
Country 30.4% from Egypt 29.7% from Egypt 29.7% from Egypt
(N ¼ 831), 10.1% from (N ¼ 404), 9.9% from (N ¼ 408), 9.8% from
Kuwait (N ¼ 275), Kuwait (N ¼ 134), 9.7% Kuwait (N ¼ 135), 9.7%
10.3% from Jordan from Jordan (N ¼ 132), from Jordan (N ¼ 133),
(N ¼ 281), 7.6% from 7.7% from Algeria 7.8% from Algeria
Algeria (N ¼ 207), 9.7% (N ¼ 105), 9.6% from (N ¼ 107), 9.5% from
from Saudi Arabia Saudi Arabia (N ¼ 130), Saudi Arabia (N ¼ 131),
(N ¼ 265), and 8.3% , and 8.7% , from Iraq and 8.7% , from Iraq
from Iraq (N ¼ 226), (N ¼ 118), and 7.3% (N ¼ 119), and 7.3%
and 6.6% from from Palestine from Palestine
Palestine (N ¼ 180), (N ¼ 99), 6.5% from (N ¼ 1001, 6.4% from
6.1% from Libya Libya (N ¼ 88), 6 % Libya (N ¼ 88), 6 %
(N ¼ 167), 5.1 % from from Lebanon from Lebanon
Lebanon (N ¼ 142), (N ¼ 82), 3.3% from (N ¼ 82), 3.3% from
3.6% from Sudan Sudan (N ¼ 45), and Sudan (N ¼ 45), and
(N ¼ 98), and 2.2% 1.7% from 1.7% from
from UAE (N ¼ 60) UAE (N ¼ 23) UAE (N ¼ 23)

Procedures
A team of three core researchers from the center of Stress Trauma and
Resiliency, Georgia State University, Atlanta, GA, and an Affiliate from the
Center for Cumulative Trauma Studies, Stone Mountain, GA (The TEAM)
previously selected the items that represent the first three components of
the construct: fear of future infection or death from COVID-19 (5items),
economic impact (4 items), routine disruption and isolation impact (4
items), and developed the initial scale. An initial study showed that the
scale had good construct, convergent-divergent, and predictive validity
 JOURNAL OF LOSS AND TRAUMA 5

(Kira et al., 2020). Based on feedback and further analysis, the scale devel-
opers determined that the scale needed further development to include
stressors related to losing close relatives and friends to COVID-19 infec-
tion. The team chose five items representing the stressors related to losing
close relatives and friends to COVID-19 infection. The choice of items was
based on screening a pool of represented item formats used to measure
grief in the literature. The items were developed in English and translated
and back-translated to Arabic by bilingual professionals. The English ver-
sion of the questionnaire is currently tested in a separate study. An
example of the items is “I have a close relative or friend who has been died
by COVID-19.” “I yes, how has this affected you?” The participant is asked
to respond on a 5 point Likert scale with (1) means not at all and (5)
means very much. (however, one of the five items was eventually deleted in
the confirmatory analysis).
The field study team of graduate students from participating Arab coun-
tries administered the questionnaires to participants in their respective
Arab countries from January to March of 2021. We chose the eleven
Arabic countries: Algeria, Iraq, Jordan, Kuwait, Lebanon, Libya, Palestine,
Saudi Arabia, Sudan, UAE, and Egypt, to represent half of the 22 Arab
countries. We used Google Drive and developed a survey link for the
online participants. Once the participant completed the survey, it was sent
anonymously to Gmail then downloaded to the Excel file. All question-
naires were administered individually to participants in their Arabic lan-
guage. The questionnaire was administered face to face¼ 17.5% and
online¼ 82.5%. We used networking and snowballing approaches in
recruiting participants. For online, each participant was asked to fill the
questionnaire and forward it to his/her friends and relatives, asking them
to fill it and forward it to their friends and relatives with the same request.
For online administration, the return rate was 84%. Participation was vol-
untary with built-in informed consent; each person took approximately
20 min to complete the full questionnaire. The sponsoring university IRB
approved the research protocol as part of a cross-cultural study of the
impact of COVID-19.

Measures
In addition to the COVID-19 stressors scale with its new added items, we
used the following measures:

Posttraumatic stress disorder checklist for DSM-5 (PCL- V)

PCL-V is a 20-item self-report measure (Blevins et al., 2015). Each item is
scored on a five-point scale with “0,” indicating “not at all” and 4
6 I. A. KIRA ET AL.

indicating “extremely.” Initial research suggests that a PCL-5 cutoff score

between 31-33 is indicative of PTSD. A provisional PTSD diagnosis can be
made by treating each item rated as 2 ¼ “Moderately” or higher as a symp-
tom endorsed, then following the DSM-5 diagnostic rule, which requires at
least: 1 B item (questions 1-5), 1 C item (questions 6-7), 2 D items (ques-
tions 8-14), 2 E items (questions 15-20). The Arabic version of PCL-V has
been previously validated in Arabic samples (Ibrahim et al., 2018).
Cronbach’s alpha reliability of the scale in the current study was .95.

Generalized anxiety disorder-7 (GAD-7)

GAD-7 is a 7-item self-report questionnaire that assesses general anxiety
(Spitzer et al., 2006). Items are scored on a 4-point scale with (0) indicating
“does not exist,” and (3) indicating “nearly every day.” The scores range
between 0-21, with a cutoff point of 15, indicating severe GAD. The GAD-
7 has a sensitivity of 89% and a specificity of 82%. Increasing scores on the
scale have been strongly associated with multiple domains of functional
impairment (Spitzer et al., 2006). The Arabic version of GAD-7 was previ-
ously validated in Arabic samples (Sawaya et al., 2016). Cronbach’s alpha
reliability for the scale in the current study was .91.
Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2001) is a 9-
item self-report questionnaire that measures the degree of depression sever-
ity. Items are scored on a 4-point scale with (0) indicating “does not exist,”
and (3) indicating “nearly every day.” The scores range between 0-27, with
a cutoff range of 15-19 indicating moderately severe depression and 20 and
above indicating severe depression. The Arabic version of PhQ-9 was previ-
ously validated in Arabic samples (Sawaya et al., 2016). Cronbach’s alpha
reliability for the instrument in the current study was .88.

The Adult Executive Functioning Inventory (ADEXI)

It was used to investigate executive functioning deficits (Holst & Thorell,
2018). The ADEXI is a 14-item scale that measures working memory defi-
cits (9 items) (e.g., “I have difficulty remembering lengthy instructions”
and inhibition deficits (5 items) (e.g., “I tend to do things without first
thinking about what could happen”). The participant is asked to rate the
statement on a scale from 1 to 5, with “1” indicating that the is definitely
not true, and “5” indicating the statement is definitely true. A higher score
indicates higher executive functioning deficits and a lower score indicates
lower deficits. The ADEXI was explicitly developed to investigate deficits in
working memory and inhibition and address the limitations of other rating
instruments of executive functioning that often include items overlapping
 JOURNAL OF LOSS AND TRAUMA 7

with ADHD symptom levels. This instrument has proven to discriminate

well between adults with and without ADHD (Holst & Thorell, 2018).
Alpha for the total scale in current data was .87, .80 for working memory,
and .70 for inhibition.

Statistical analysis
The data were analyzed utilizing IBM-SPSS 22 and Amos 22 software. The
inspection of the variables indicated that there are no missing values in the
data as the survey was designed such that it was not possible to proceed
without entering a response to each item. We conducted an exploratory
and confirmatory factor analysis to test the COVID-19 traumatic stress
scale’s structural validity. Since it is generally recommended to conduct
exploratory and confirmatory factor analysis on separate samples, we drew
two random sub-samples from the main sample (N ¼ 2732) using “select
cases (50% random)". The first random sub-sample included 1360 partici-
pants and the second remaining subsample included 1372. There were no
significant differences in most of the demographics between these two sub-
samples. For the demographic characteristics of the two subsamples, see
Table 1. We conducted an exploratory factor analysis on the first sub-
sample and a confirmatory factor analysis on the second subsample.
Further, we conducted a second-order confirmatory analysis to see if the
second-order model fit the data. Following Byrne’s (2012) recommenda-
tions, the criteria for good model fit were a non-significant (v2), (v2/d.f. >
2), comparative fit index (CFI) values > 0.90, and root-mean-square error
of approximation (RMSEA) values < 0.08. However, because v2 criteria are
sensitive to sample size (e.g., Meade & Lautenschlager, 2004), we did not
apply the v2 criteria as the current sample size was very high (N ¼ 2732).
We then investigated the reliability of the scale with Cronbach’s alpha
and conducted a multi-group invariance analysis to assess whether the
second-order measurement model of COVID-19 traumatic stressors was
invariant across genders. We tested four nested measurement and seven
structural models sequentially: a configural invariance model, two metric
invariance models (measurement and structural), two scalar invariance
models (measurement and structural), and two strict invariance models
(measurement and structural). In the configural model (i.e., equal form),
the parameters were all freely estimated across groups. In the metric model
(i.e., weak or partial invariance), the parameters were constrained to be
identical across groups. In the scalar model or “strong invariance,” variables
and path variances were set to be equal across groups. Lastly, the strict
model “strict invariance” additionally constrained the residuals to be the
same across groups.
8 I. A. KIRA ET AL.

Although there is broad acceptance of the steps for testing measurement

and structural invariance, the criteria for evaluating the invariance of
models at each level are not as clear. Chi-square tests LRT is highly
sensitive to sample size (e.g., Meade & Lautenschlager, 2004), potentially
leading to an excessively conservative test of invariance and is controversial
in use with large samples (note that the second sample size ¼ 1372).
Byrne et al. (1989) have argued that invariance can be established as long
as at least two indicators indicate invariance. According to Chen (2007),
the null hypothesis of invariance should not be rejected when changes in
CFI are less than or equal to 0.01 and in RMSEA are less than or equal
to 0.015.
In psychometrics, criterion validity is the extent to which a measure is
related to an outcome. Criterion validity is often divided into concurrent
and predictive validity based on the timing of measurement for the
“predictor” and outcome (Cronbach, & Meehl, 1955) page 282. To test the
Criterion and predictive validity of COVID-19 traumatic stress, we con-
ducted a zero-order correlation between COVID-19 and its sub-scales and
measures of PTSD, depression, and anxiety. We assumed that increased
PTSD, depression, anxiety are expected outcomes of COVID-19 traumatic
stressors, and this will provide evidence of their predictive validity. To
determine the significance of the comparison between correlation sizes, we
used Lee and Preacher (2013), software to calculate the fisher z score for
comparing correlations (see also Steiger, 1980).

Results
Principal and confirmatory factor analysis(structural validity)
Using principal axis factoring analysis and Oblimin rotation in the first
sub-sample (N ¼ 1360), four factors were extracted. The four factors
accounted for 60.57% of the variance and exceeded the 95th percentile of
eigenvalues of factors derived from random data using parallel analysis
(O’Connor, 2000). The first factor included items clearly representing the
fear of the present and future infection or death from traumatic infection
stressors and accounted for 33.93% of the variance. The second factor
included items representing economic stressors and traumas and loaded on
items of lost jobs and financial difficulties and accounted for 10.99% of the
variance. The third factor was a robust factor for grief stressors and
accounted for 8.72%of the variance. The fourth factor including items
measuring isolation and disturbed routine (lockdown) and accounted for
6.94% of the variance. Table 2 details the items, their factor loadings, and
commonalities.
 JOURNAL OF LOSS AND TRAUMA 9

Table 2. The four COVID-19 traumatic stressors factors extracted from the first split subsample
(N ¼ 1360), the percentage of the variance each accounted for, their loadings and
communalities.
Factors and their % of the variance
1 2 3 4
Items (.33.93%) (10.99%) (8.72%) (6.94%) Comm.
I am afraid of the coronavirus (COVID-19). .907 .014 .001 .071 .781
I am stressed around other people because I worry I’ll .893 .040 .025 .007 .764
catch the coronavirus (COVID-19).
How concerned are you that you’ll be infected with .819 .043 .012 .041 690
the coronavirus?
Thinking about the coronavirus (COVID-19) makes me .807 .120 .038 .003 .731
feel threatened.
Over the past two weeks, I have felt nervous and .706 .024 .036 .181 .668
fearful about the future because of the coronavirus.
I have lost job-related income due to the Coronavirus .037 .844 .020 .087 .698
(COVID-19).
The Coronavirus (COVID-19) has impacted me .139 .752 .051 .041 .672
negatively from a financial point of view.
I have had a hard time getting needed resources due .042 .521 .023 .313 .528
to the Coronavirus (COVID-19).
It has been difficult for me to get the things I need .040 .470 .005 .353 .517
due to the Coronavirus (COVID-19)
I have a close relative or friend who has been died by 061 .210 .733 .227 .543
COVID-19.
I have a close relative or friend who has been infected .141 .214 .702 .124 .518
by COVID-19.
How this affected you? .218 .023 .691 .002 .620
To what extent that happened to your friends and .255 .054 .576 173 .576
relatives because COVID-19 affected you?
To what extent has your neighborhood been infected .071 .049 .540 .113 .375
with the coronavirus?
Over the past two weeks, I have felt socially isolated .006 .084 .005 .750 .608
as a result of the coronavirus.
To what extent have you sheltered in place (stayed .047 .173 .078 .738 .530
home except for essential outings)?
What is the extent to which sheltering in place has .098 .135 .009 .634 .564
negatively affected your relationships with others?
Over the past two weeks, my life routines have been .158 .055 .052 .608 .520
disrupted by the coronavirus situation
Note: Comm.¼ Communalities.
Bold values are the significnt loading on each factor.

We conducted a confirmatory factor analysis using Amos 22 software on

the second sub-sample (N ¼ 1372). However, because the item” To what
extent has your neighborhood been infected with the coronavirus?” loaded
less than .4 in the confirmatory analysis, it was deleted from the final ver-
sion. The four-factor solution fit well without correlated errors (Chi Square
¼ 1070.137, d.f.¼113,p ¼ .000, CFI ¼ .900, RMSEA ¼ .079). When we
conducted some recommended correlated errors, the model fit significantly
increased (Chi Square ¼ 547.173, d.f.¼118,p ¼ .000, CFI ¼ .950, RMSEA
¼ .056). Also, we tested the second-order model with COVID-19 stressors as
a second-order factor represented by the four correlated stressor types (fears,
economic, grief, and lockdown stressors). The model fit well without corre-
lated errors (Chi Square ¼ 735.784, d.f.¼114, p ¼ .000, CFI ¼ .935, RMSEA
10 I. A. KIRA ET AL.

Figure 1. Confirmatory factor analysis for the second-order factor of COVID-19 Stressors.

¼ .063) and the fit increased after conducting some recommended correlated
errors (Chi Square ¼ 547.173, d.f. ¼ 105, p ¼ .000, CFI¼.954,
RMSEA¼.056). Figure 1 presents the confirmatory factor analysis results for
the second-order factor after conducting the recommended correlated errors.

Measurement invariance between gender (male/female)

Multigroup structural invariance indicated that the measurement model of
the second-order COVID-19 stressors is strictly invariant between genders
 JOURNAL OF LOSS AND TRAUMA 11

Table 3. Multigroup Measurement Invariance Analysis of fo the COVID-19 stressors Scale

across genders (male/female).
Gender (Male/female) x2 df p x2 /df CFI RMSEA IFI TLI
Unconstrained (Configural) 992.803 228 .000 4.354 .912 .049 .912 .906
Measurement weights (Metric) 1033.222 241 .000 4.287 .919 .049 .919 .908
Measurement intercepts (Scalar) 1156.094 258 .000 4.481 .908 .050 .908 .903
Structural weights (Metric) 1160.536 261 .000 4.446 .908 .050 .908 .904
Structural covariances 1161.291 262 .000 4.432 .908 .050 .908 .904
Structural residuals 1166.952 266 .000 4.387 .908 .050 .908 .906
(Strict invariance)
Measurement residuals 1213.515 284 .000 4.273 .905 .049 .905 .909
(Strict invariance)

(males and females). Table 3 includes the structural fit indexes on the four
levels (configural, metric, scalar, and strict) for the measurement and struc-
tural levels, which did not significantly differ from each other according to
the criteria previously discussed.

Reliability
The internal consistency reliability (alpha) for the total COVID-19 trau-
matic stress scale was .88. The alpha for the future infection/death subscale
was .90, .75 for the economic stressors subscale, .76 for the routine distur-
bances subscale, and .72 for the grief subscale.

Correlations: (criterion/predictive validity)

All four of the COVID-19 stressors subscales and the total scale score were
significantly correlated with PTSD, depression, anxiety, working memory
deficits, and inhibition deficits except for the COVID-19 economic stressors
subscale which was not significantly related to inhibition deficits. These
results provide evidence of the criterion and predictive validity of the
COVID-19 stressors scale and its four subscales. COVID-19 lockdown-
related stressors (and COVID-19 cumulative stressors) had higher correla-
tions with mental health and cognitive variables than the other three
COVID-19 stressor types. The difference between the size of correlations of
lockdown-related stressors (and COVID-19 cumulative stressors) and
COVID-19 economic stressors (The subsequent highest correlation) in
PTSD (z score¼ 5.43, p(two tails)¼ 0.000) and depression (z score¼ 5.99,
p(two tails)¼ 0.000) were significant. The difference between the size of
correlations of lockdown-related stressors (and COVID-19 cumulative
stressors) and COVID-19 fears (the next highest correlation) in anxiety (z
score¼ 4.47, p(two tails)¼ 0.000) was also significant. The difference
between the size of correlations of lockdown-related stressors (and
COVID-19 cumulative stressors) and COVID-19 fears (the next highest
correlation) in working memory deficits (z score¼ 4.77, p(two tails)¼
 12

Table 4. Zero-order correlations between COVID-19 traumatic stressors scale and its subscales and its predictive mental healthe and cognitive variables.
Variable 1 2 3 4 5 6 7 8 9 10
1.COVID-19 Fears 1
2.COVID-19 Economic Stressors .40 1
3.COVID-19 Isolation (lockdown) stressors .51 .48 1
4.COVID-19 Grief stressors .45 .22 .36 1
5.COVID-19 Cumulative Stressors .85 .67 .77 .67 1
6.PTSD .22 .24 .34 .19 .32 1
I. A. KIRA ET AL.

7.Depression .22 .24 .35 .20 .33 .71 1

8.Anxiety .25 .24 .33 .20 .34 .70 .78 1
9.Working memory deficits .09 .08 .17 .12 .15 .43 .38 .34 1
10.Inhibition deficits .04 .04 .19 .12 .12 .49 .42 .38 .73 1
Note: p < .05, p < .01, p < .001.
Note: PTSD: posttraumatic stress disorder.
 JOURNAL OF LOSS AND TRAUMA 13

0.000) and inhibition deficits z score¼ 8.02, p(two tails)¼ 0.000) were also
significant. Table 4 presents the correlation results.

Conclusion and discussion

Most previous research on the impact of COVID-19 on mental health has
focused on a specific stressor. While such studies are valuable and inform-
ative, they do not adequately measure the pandemic’s global and cumula-
tive impact. The current measurement approach outlined in this study
provides evidence for a COVID-19 measurement strategy that includes a
more robust consideration of the pandemic’s various stressors and their
cumulative impact. The measurement model has robust psychometrics with
good structural and criterion validity, reliability, and invariance across gen-
ders. These results build on a previous study that offered evidence for the
concurrent and divergent validity for three of the four subscales included
in this study (Kira et al., 2020). The second-order results emphasized that
the measure’s total score can be used to measure the cumulative effects of
the four COVID-19 stressor types, which are significantly related to
one another.
The validated measure resulting from this study has the advantage of
being able to assess most, if not all, the different stressor types related to
COVID-19 cumulatively or individually and assesses their differential and
total impact. It also clearly distinguishes between COVID-19 stressors and
the outcome distress or anxiety related to them, providing a more straight-
forward measurement tool that does not mix stressors with the resulted
stress/distress. Considering that COVID-19 stressors are continuous and
developing, using the measure longitudinally will allow comparisons of the
different trajectories and changes in their impact over time. Also, the meas-
ure could be modified to measure different pandemic and epi-
demic stressors.
While highlighting the new measurement model’s robust psychometrics
and utility, the study results suggest the severe impact of COVID-19 differ-
ent stressor types and their cumulative effects on mental health and execu-
tive function. The findings that lockdown and related stressors have the
largest effect on the mental health and cognitive functioning variables
measured in the current study suggest the need to further explore the
dynamics of this impact and the progression of continuous COVID-19
impact over time. This is of particular interest because, in a previous study,
conducted in seven Arab countries from April to May 2020 (about ten
months before the current study), economic stressors were found to have
the worst impact on well-being (Kira et al., 2020; Shuwiekh et al., 2020). It
may be that, with the long continuous or intermittent exposure to
14 I. A. KIRA ET AL.

lockdown and its strict measures, lockdown stressors became the stressors
that have the largest impact on well-being compared to other COVID-19
stressors (e.g., infection fears, grief, and economic stressors).
The results of the current study highlight the seriousness of the effect of
COVID-19 cumulative and continuous impact and suggest that it may rep-
resent a unique trauma not currently accounted for in dominant traumatic
stress paradigms (Kira, 2021; Kira et al., In Press). Its impact appears to go
beyond traditional effects on PTSD, depression, and anxiety to executive
function deficits, suggesting the concept of a possible Post-COVID-19 trau-
matic stress syndrome/disorder. There is clearly a need for future studies
that further explore the other potential components and symptoms of this
possible syndrome, such as dissociation, psychotic features, and suicidality.
The results of this study suggest that there is a need for innovation in clin-
ical interventions and prevention beyond current PTSD treatments that
address the complex constellation of effects found. Future studies might
also explore aspects of resiliency and posttraumatic growth that may
develop after exposure to such a syndrome.
The current study has several limitations. One of the limitations is that
the study was conducted with a convenient sample that is relatively skewed
toward younger and female participants. Another limitation to the study is
that the measures used are based solely on participants’ self-report, which
could result in the under-or over-reporting due to current symptoms,
embarrassment, shame, or social desirability. Further, the samples in the
current study represented only Arab cultures. Using the measure on
Western and other non-Western cultures and testing its invariance across
cultures in future studies is essential. Further, we did not test the discrim-
inant validity of the measure and whether its four subscales measured dif-
ferent things. Future studies should be conducted to test the discriminant
validity of the measure and its subscales.

Acknowledgments
The authors are grateful to Engineers and graduate students: Idris Badie from Libya, Fahd
Jalal from Iraq, Ruslan Uday from Saudi Arabia, Agwad Badawy from Jordan, Arshad Basil
from Palestinian, Naji Ghatawan from Lebanon, Hamza Ayyash from Emirates, Bilal Hajj
from Algeria and Said Aaron from Sudan., for their superb leadership in the data collection
procedure from their respective countries.

Notes on contributors
Ibrahim A. Kira is the Director of the center of cumulative Trauma Studies, Stone
Mountain, GA, USA (An International virtual research organization). His areas of interest
include Stress and Trauma dynamics, identity, and resiliency. He is the lead developer of
the development-based taxonomy of stressors and traumas.
 JOURNAL OF LOSS AND TRAUMA 15

Hanaa A.M. Shuwiekh is a professor and head of the psychology department at the
University of Fayoum, Egypt. Her areas of interest include stress and trauma, gender issues,
and resiliency.
Jeffrey S. Ashby is a Professor of Counseling Psychology and the Co-Director of The
Center for the Study of Stress, Trauma, and Resilience at Georgia State University, Atlanta,
GA, USA. His interests include stress and trauma dynamics, Perfectionism, and counsel-
ing techniques.
Kenneth G. Rice is a Professor in the Department of Counseling and Psychological Services
and co-director of the Center for the Study of Stress, Trauma, and Resilience at Georgia
State University, Atlanta, GA, USA. His research interests include how stress, personal
characteristics such as perfectionism, and situational or social factors interact and affect a
range of health, mental health, academic, and work-related outcomes.
Amthal Alhuwailah is Lecturer, Department of Psychology, College of Social Sciences, and
Head of the Family Center, College of Social Sciences at Kuwait University. Her interests
include traumatic stress, resilience, spirituality, and motivation.

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