Death Studies

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Validation of the Korean version of the obsession

with COVID-19 scale and the Coronavirus anxiety
scale

Eunsoo Choi, Jihoon Lee & Sherman A. Lee

To cite this article: Eunsoo Choi, Jihoon Lee & Sherman A. Lee (2020): Validation of the Korean
version of the obsession with COVID-19 scale and the Coronavirus anxiety scale, Death Studies,
DOI: 10.1080/07481187.2020.1833383

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DEATH STUDIES
https://doi.org/10.1080/07481187.2020.1833383

REPORT

Validation of the Korean version of the obsession with COVID-19 scale and
the Coronavirus anxiety scale
Eunsoo Choia , Jihoon Leeb, and Sherman A. Leec
a
Department of Psychology, Korea University, Seoul, Korea; bAsan Medical Center, Songpa-gu, Korea; cDepartment of Psychology,
Christopher Newport University, Newport News, Virginia, USA

ABSTRACT
In response to the current COVID-19 pandemic, the Obsession with COVID-19 scale (OCS)
and the Coronavirus Anxiety Scale (CAS) were developed as screening tools for dysfunc-
tional anxiety associated with the coronavirus. These scales have not yet been validated in
the East Asia. The present study examined the validity of the OCS and the CAS with a sam-
ple of 329 Korean adults. We found that the OCS-Korean and CAS-Korean showed good psy-
chometric properties and construct validity. Developing such valid screening tools across
different cultures is vital for health practitioners and scholars alike during global infectious
disease outbreaks.

Six months have passed since World Health
Organization (WHO) declared the COVID-19 (SARS-
C0V-2) outbreak and there are over 22 million con-
firmed cases and more than 770,000 deaths around
the globe (WHO, 2020). The COVID-19 outbreak
poses a threat not only to physical health, but to men-
tal health as well. Due to the unknown and complex
nature of the disease, people around the globe face
unprecedented uncertainties and life changes that
have resulted in prolonged stress and increased risk
for psychological dysfunction. Indeed, recent studies
have documented increased anxiety (Wang et al.,
2020), depression (Wang et al., 2020), and sleep dis-
turbances (Xiao et al., 2020) associated with fear and
anxiety about COVID-19 (Ahorsu et al., 2020; Lee
et al., 2020). Several studies have revealed that corona-
virus related fear and anxiety explain psychological
distress and dysfunction above demographics, person-
ality, and COVID-19 factors (Lee et al., 2020; Lee &
Crunk, 2020). Pandemic-related fear has also been
linked to cases of suicide (Goyal et al., 2020; Mamun
& Griffiths, 2020). As such, reliable and valid meas-
urements to assess psychological dysfunction related
to the COVID-19 pandemic in the population are
vital to identifying individuals with mental dysfunc-
tion related to the COVID-19 pandemic and to pro-
vide support and interventions in a timely manner
(Holmes et al., 2020).
In response to the current pandemic, the Obsession
with COVID-19 scale (OCS; Lee, 2020a) and the
Coronavirus Anxiety Scale (CAS; Lee, 2020b) were
among the first screening tools developed for assessing
dysfunctional coronavirus anxiety and obsession with
the COVID-19. The OCS measures individuals’ exces-
sive and repetitive thinking about COVID-19, while
the CAS measures individuals’ physiologically-based
reactions of fear and anxiety to coronavirus related
information. Both scales have solid psychometric
properties and have been validated in the United
States (Lee, 2020a, 2020b), Bangladesh (i.e., CAS,
Ahmed et al., 2020), Turkey (i.e., CAS; Ladikli et al.,
2020; Evren et al., 2020), and Pakistan (i.e., OCS,
Ashraf et al., 2020). The CAS has even been success-
fully been adapted for healthcare professionals in
Mexico (Mora-Maga~ na et al., 2020). However, to date,
no known study has developed instruments to assess
psychological dysfunction related with the COVID-19
pandemic in South Korea. Thus, we aimed to validate
the OCS and the CAS, originally developed in
English, in the Korean language with Korean adults.
Methods
Study context
South Korea was among the first countries to see a
rapid surge of coronavirus infections in late February
and early March 2020 and was once in second place

CONTACT Eunsoo Choi taysoo@korea.ac.kr Department of Psychology, Korea University, 145 Anam-ro, Sungbuk-gu, Seoul 02841, Korea.
ß 2020 Taylor & Francis Group, LLC
2 E. CHOI ET AL.
in terms of total number of cases after China in the
world. However, through widespread testing and thor-
ough contact tracing, South Korea successfully
“flattened the curve” of new infections and now has
one of the lowest infection rates among the high-
income countries in the world (Fisher & Choe, 2020).
Despite its successful containment of the COVID-19,
people in South Korea still perceive infection-related
threat of COVID-19 due to the risk of resurgence,
particularly with infection rates surging in other coun-
tries around the world. At the time of writing
(between June 20th and July 20th), South Korea just
elevated the social distancing guidance from Level-1
to Level-2, after seeing a surge in coronavirus cases
and the Korean Center for Disease Control
announced that the government will adopt Level-3
social distancing that ban all meetings of 10 people or
more, if the situation becomes worse (Park, 2020).
Participants and procedure
The research company Dataspring (https://www.
d8aspring.com) recruited participants using online
survey from July 13th to July 14th, 2020. A sample of
329 Korean adults comprising 182 males (55.3%) and
147 females (44.7%) with a combined mean age of
40.60 years (SD ¼ 10.93) ranging from 21 to 66 years
was recruited. More than half of the participants were
college graduates (57.4%), 10% had upper-level
degrees, 14.6% had some college education, and 17.9%
were high school graduates. The mean level of their
annual income was 5.60 (approximately 51 million
Korean Won). This study was approved by the
Institutional Review Board at Korea University
(2020-0168).
Measures
Obsession with COVID-19 Scale-Korean Version
(OCS-Korean Version)
The Obsession with COVID-19 Scale (OCS) is a self-
report type mental health screener that measures per-
sistent disturbing thinking associated with COVID-19
(Lee, 2020b). Lee (2020b) developed this scale and
demonstrated its reliability and validity on two large
samples (N ¼ 775; N ¼ 398) of adult residents in the
United States. The OCS has four items each rated on
a 5-point scale from 0 (not at all) to 4 (nearly every
day over the last two weeks). A total score 7 indi-
cates probable dysfunctional thinking about COVID-
19. In this study, the Korean version of the OCS was
translated by one of the researchers, proofread by a
bilingual peer researcher, and finalized by a profes-
sional translator.
Coronavirus Anxiety Scale-Korean Version (CAS-
Korean Version)
The Coronavirus Anxiety Scale (CAS) was developed
by Lee (2020b) to differentiate individuals who were
functionally impaired by anxiety about COVID-19
from those anxious, but not disabled by their emo-
tional reactions to the disease. A series of studies (Lee,
2020b; Lee & Crunk, 2020; Lee et al., 2020) demon-
strated that the CAS is a reliable self-report measure
(a ¼ 0.92), having solid factorial validity across socio-
demographic variables as well as evidence of construct
validity with correlations with anxiety, depression, sui-
cidal ideation, and drug/alcohol coping. The CAS has
five items and is rated on a 5-point scale from 0 (not
at all) to 4 (nearly every day over the last two weeks).
Although the total score of 9 was reported as clinic-
ally anxious in the initial study, probably because the
validation sample had been exposed to media coverage
on COVID-19 for more than one hour over the last
two weeks or to experiences of anxiety or fear about
the disease (Lee, 2020a), the cutoff score was lowered
to 5 for the general public, so that sensitivity and
specificity rates were adjusted to 71% and 74%,
respectively (Lee et al., 2020). In this study, the
Korean version of the CAS was translated by the one
of the researchers, proofread by a bilingual peer
researcher, and finalized by a professional translator.
Patient Health Questionnaire (PHQ-4)
The PHQ-4 is a 4-item composite scale comprising
the first two items of the Patient Health
Questionnaire (PHQ-9) and of the Generalized
Anxiety Disorder (GAD-7) (Kroenke et al., 2009). The
original nine-item measure (PHQ-9) identifies depres-
sive disorder with excellent reliability, criterion, con-
struct, and procedural validity. Also, a 7-item measure
(GAD-7) assesses symptoms of the four most com-
mon anxiety disorders, such as generalized anxiety,
panic, social anxiety, and posttraumatic stress disor-
ders with solid validity and reliability (Kroenke et al.,
2009). The PHQ-2 and the GAD-2 have two core cri-
teria for depressive disorders and for generalized anx-
iety disorder, respectively. A score of 3 on the
Anxiety subscale of the PHQ-4 indicates clinical anx-
iety, while a score of 3 on the Depression subscale
of the PHQ-4 defines clinical depression. In this
study, a Korean version of the PHQ-4 was created by
one of the researchers and proofread and corrobo-
rated by another peer researcher.

Work and social adjustment scale
The Work and Social Adjustment Scale (WSAS) is a
self-report measure that assesses functional impair-
ment associated with a mental disorder. Former stud-
ies support that the WSAS is a reliable and clinically
useful tool that measures subjectively perceived dis-
ability due to a psychological condition (Pedersen
et al., 2017). The original four-item measure was
improved to five-item measure as it is currently used.
The WSAS measures impairment in ability to work or
study, home management, social leisure activities, pri-
vate leisure activities, and ability to maintain close
relationship on a 9-point Likert scale from 0 (not at
all) to 8 (severely impaired). According to Mundt
et al. (2002), total WSAS scores above 20 suggest
severe or worse psychopathology, scores from 10 to
20 significant functional impairment but less severe
clinical symptomatology, and below 10 indicate sub-
clinical impairment. In this study, a Korean version of
the WSAS was created and translated by one of the
researchers and proofread and corroborated by
another peer researcher.
Data analysis
First, we conducted a series of confirmatory factor
analyses (CFA) on the OCS and the CAS to assess the
factor structure of these constructs with a sample
from the South Korean population. Following the
conventional standards (Brown, 2006; Byrne, 2001),
adequate model fit was defined by a root mean square
error of approximation (RMSEA)  0.10, a standar-
dized root-mean-square residual (SRMR) value 
0.05, comparative fit index (CFI), and Tucker Lewis
index (TLI) values 0.90. We did not use the chi-
square ratio as a criterion for fit statistics due to its
sensitivity to sample size (Brown, 2006). Next, we
examined the concurrent validity of the Korean ver-
sions of the OCS and CAS using zero-order correla-
tions with total scores on the WSAS, PHQ-4 (anxiety,
depression). We expected to find positive correlations
between the measures because previous research has
shown that fear and anxiety of COVID-19 is strongly
associated with depression, anxiety, and functional
impairment. We also extended this investigation with
a series of regression analyses to determine if the OCS
and CAS independently explain psychological distress
and dysfunction. Although this is the first comparative
analysis conducted between these measures of
COVID-19 related anxiety, we expected them to
explain unique variance as they purportedly measure
DEATH STUDIES 3
different aspects of the anxiety construct (i.e., obses-
sive thinking vs. bodily reactions of fear and anxiety).
Results
Obsession with Coronavirus Scale (OCS)
Item and sociodemographic analyses
Table 1 presents percentages of responses on each
response scale, descriptive statistics (means, standard
deviations), and item metrics of the OCS. The OCS
Korean version demonstrated satisfactory internal
consistency reliability with a Cronbach’s alpha of 0.72.
For exploratory purposes, we ran a regression ana-
lysis to see whether the OCS scores would vary by
sociodemographic factors including age, sex, education
level, income, and political orientation. Age negatively
predicted OCS; that is, older adults scored lower than
younger adults, B ¼ 0.06, SE ¼ 0.01, t(270) ¼ 4.20,
p < .001, 95% CI[–0.088, 0.032]. All other sociode-
mographic variables were not associated with the
OCS. Based on the cutoff score 7 in the original
findings (Lee, 2020b), 5.5% of the present sample was
classified as having dysfunctional COVID-19 think-
ing patterns.
Confirmatory factor analysis
A CFA was conducted to test whether OCS Korean
version has a single-factor structure as reported in the
original OCS scale paper (Lee, 2020b). The single-fac-
tor model showed an excellent fit for all indices (v2/
df ¼ 4.576, CFI ¼ 0.994, TFI ¼ 0.982, RMSEA ¼
0.063, SRMR ¼ 0.021). Factor loadings ranged from
0.45 (item 4) to 0.83 (item 2). To further examine
whether OCS was measured equivalently for men and
women, a multigroup CFA was conducted. The results
demonstrated that the configural model of gender
yielded excellent model fit (v2/df ¼ 4.485, CFI ¼
0.999, TFI ¼ 0.997, RMSEA ¼ 0.027, SRMR ¼ 0.016),
suggesting that the OCS Korean version was valid
measure for both genders.
Coronavirus Anxiety Scale (CAS)
Item and sociodemographic analyses
Table 2 presents percentages of responses on each
response scale, descriptive statistics (means, standard
deviations), and item metrics of CAS. The CAS
Korean version demonstrated good internal consist-
ency reliability with a Cronbach’s alpha of 0.85.
For exploratory purposes, we ran a regression ana-
lysis to see whether the CAS scores would vary by
sociodemographic factors. The regression analysis
 4
E. CHOI ET AL.

Table 1. Descriptive and psychometric properties of the items of obsession with COVID-19 Scale–Korean Version.
Response scale Descriptive Item metrics
0 1 2 3 4 M SD ITC SMC CID Factor loading
Item 1. I had disturbing thoughts that I may have caught the coronavirus. 48.0 44.7 4.3 1.5 1.5 0.64 0.77 0.67 0.47 0.69 0.77
Item 2. I had disturbing thoughts that certain people I saw may have the coronavirus. 40.4 46.2 7.6 3.6 1.8 0.80 0.87 0.70 0.52 0.67 0.83
Item 3. I could not stop thinking about the coronavirus. 52.3 28.9 10 3.3 5.5 0.81 1.10 0.67 0.45 0.71 0.75
Item 4. I dreamed about the coronavirus. 87.8 8.5 2.4 0.9 0.0 0.16 0.49 0.42 0.18 0.81 0.45

Table 2. Descriptive and psychometric properties of the items of Coronavirus Anxiety Scale–Korean Version.
Response scale Descriptive Item metrics
0 1 2 3 4 M SD ITC SMC CID Factor loading
Item 1. I felt dizzy, lightheaded, or faint, when I read or 79.3 15.8 2.1 1.5 1.2 0.29 0.70 0.66 0.47 0.82 0.76
listened to news about the coronavirus.
Item 2. I had trouble falling or staying asleep because I 70.5 23.4 4.6 0.9 0.3 0.37 0.65 0.62 0.41 0.83 0.70
was thinking about the coronavirus.
Item 3. I felt paralyzed or frozen when I thought about 89.4 7.9 1.2 0.3 0.6 0.14 0.49 0.69 0.50 0.81 0.79
or was exposed to information about the
coronavirus.
Item 4. I lost interest in eating when I thought about or 76.0 20.4 1.2 1.5 0.9 0.31 0.66 0.70 0.54 0.80 0.70
was exposed to information about the coronavirus.
Item 5. I felt nauseous or had stomach problems when 86.3 10.0 2.7 0.3 0.3 0.18 0.51 0.66 0.49 0.82 0.66
I thought about or was exposed to information
about the coronavirus.
Note. M ¼ mean, SD ¼ standard deviation, ITC ¼ item-total correlation, SMC ¼ squared-multiple correlation, CID ¼ Cronbach’s alpha if item is deleted.
 DEATH STUDIES 5

Table 3. Regression explaining WSAS, PHQ-4 Anxiety, and PHQ-4 Depression with OCS and CAS as Predictors.
WSAS PHQ-4 Anxiety PHQ-4 Depression
B SE Beta t B SE Beta t B SE Beta t
OCS 0.63 0.19 0.21 3.39 0.30 0.05 0.32 5.70 0.19 0.07 0.17 2.83
CAS 0.30 0.05 0.36 6.04 0.09 0.01 0.34 6.17 0.11 0.02 0.37 6.08
Note. WSAS ¼ Work and Social Adjustment Scale; PHQ-4 ¼ Patient Health Questionnaire; OCS ¼ Obsession with COVID-19 Scale; CAS ¼ Coronavirus Anxiety
Scale.  p < .01,  p < .001.

showed that only age was significantly associated with Table 4. Descriptive statistics and correlations among the
the CAS in Koreans. Age negatively predicted CAS; study variables.
that is, older adults scored lower than younger adults, Mean SD CAS OCS WSAS Anxiety Depression
OCS 0.60 0.65 – 0.588 0.423 0.522 0.380
B ¼ 0.04, SE ¼ 0.01, t(273) ¼ 2.70, p < .001, 95% CAS 1.29 2.39 – 0.487 0.532 0.469
CI[–0.065, 0.010]. All other sociodemographic varia- WSAS 2.99 1.98 – 0.494 0.423
Anxiety 1.48 0.61 – 0.752
bles, gender, education level, income, and political Depression 1.59 0.72 –
orientation, were not associated with the CAS (see Note. OCS ¼ Obsession with COVID-19 Scale; CAS ¼ Coronavirus Anxiety
Table 3 for full regression results). Based on the cutoff Scale; WSAS ¼ The Work and Social Adjustment Scale (WSAS).  p
< .001.
score 9 in the original findings (Lee, 2020a), 3.3% of
the present sample was classified as having dysfunc-
functioning (WSAS), anxiety (PHQ-4 anxiety sub-
tional levels of anxiety of coronavirus.
scale), and depression (PHQ-4 depression subscale),
Confirmatory factor analysis suggesting that the two new scales have concurrent
A CFA was conducted to test whether the CAS validity. Table 4 shows the full correlational relation-
Korean version was also a valid unidimensional con- ships among all variables as well as the descriptive sta-
struct. The CFA results confirmed that the single-fac- tistics for these constructs.
tor model yielded a good fit for all indices (CFI ¼ We conducted regression analyses separately for
0.943, TFI ¼ 0.887, RMSEA ¼ 0.153, SRMR ¼ 0.043), WSAS, anxiety, and depression to determine whether
except for RMSEA ¼ 0.153. Modification indices indi- the OCS and the CAS independently explained these
cated that adding a covariance between error varian- outcomes. As expected, the results showed that the
ces for item 4 and item 5 improved the model fit, OCS and CAS uniquely contributed to explaining the
consistent with previous research (Mora-Maga~ na variances of WSAS, anxiety, and depression scores
et al., 2020). The modified model yielded excellent fit (see Table 3). Thus, these results demonstrate that the
for all indices, CFI ¼ 0.987, TFI ¼ 0.968, SRMR ¼ OCS and the CAS are distinct anxiety constructs that
0.022, RMSEA ¼ 0.081 [0.033, 0.134; 95% CI]. Factor have unique explanatory power for predicting func-
loadings ranged from 0.66 (item 5) to 0.79 (item 3). A tional impairment and psychological distress.
multigroup CFAs was run to examine if the CAS scale
was measured equivalently for men and women. Discussion
Although the RMSEA ¼ 0.112 did not meet the crite-
ria for good fit, the overall configural model of gender We found that the OCS-Korean and CAS-Korean
had good model fit for the other indices (CFI ¼ showed good psychometric properties and construct
0.979, TFI ¼ 0.947, SRMR ¼ 0.031). validity. Specifically, the factor structure for OCS-
Korean and CAS-Korean yielded good statistical fit
indices and both measures uniquely predicted impair-
Construct validity ment in work and social adjustment as well as higher
Construct validity of OCS-Korean and CAS-Korean levels of anxiety and depression. Despite one statistic
was examined by looking at the correlations between barely exceeding the criterion value for good fit by
these measures with impairment in functioning, anx- 0.01, the results of this study largely support the use
iety, and depression. First, total scores of the OCS- of these measures for both genders in South Korea.
Korean was moderately correlated with CAS Korean These findings corroborate previous findings that the
version, r(321) ¼ 0.588, p < .001, indicating that the COVID-related thoughts can have detrimental associa-
OCS-Korean and CAS-Korean measure closely related tions with one’s mental well-being (Lee et al., 2020;
but distinct constructs. Both CAS-Korean and OCS- Wang et al., 2020). The present research was also the
Korean were positively associated with impairment in first to demonstrate that the CAS and OCS are
6 E. CHOI ET AL.
related, but distinct measures of COVID-19 related
anxiety by showing that the obsession with the cor-
onavirus can disturb mental well-being independent
of the physiological reactions of fear and anxiety over
coronavirus thoughts and information, and vice versa.
Given the findings of the present research, healthcare
professionals and researchers would benefit by using
both the OCS-Korean and the CAS-Korean as screen-
ers to identify probable cases of dysfunctional corona-
virus anxiety and obsession as they can independently
predict the levels of one’s psychological distress.
However, although excessive levels of obsession and
anxiety of COVID-19 can have adverse effects on psy-
chological dysfunction, it is worthwhile to note that a
healthy degree of fear of the coronavirus may be
beneficial since it is known to be associated with self-
protective actions (Milman et al., 2020).
This study has two limitations. First, our partici-
pants were based on a convenience sample of adults
who were recruited using an online service. Although
this approach is common in psychological research,
researchers should replicate this study using a prob-
abilistic sampling method so that the results could
generalize to the South Korean popular at large and
reduce problems associated with self-selection bias.
Second, the cross-sectional design of the study made
it impossible to establish the causal relationship
between the COVID-19 anxiety scales and the meas-
ures of psychological well-being and functional
impairment. A longitudinal research design could pro-
vide greater insight into the directional relationships
among the study variables.
Disclosure statement
No potential conflict of interest was reported
the author(s).
Funding
The present research was supported by Korea University
Future Research Grant [Grant number: K2007861].
ORCID
Eunsoo Choi http://orcid.org/0000-0003-1502-4788
Sherman A. Lee http://orcid.org/0000-0003-1878-3472
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DEATH STUDIES 7
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