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Reviewing the Psychometric Properties and Factor Structure of the

Generalized Anxiety Disorder-7 (GAD-7) in a Sample of Puerto Rican Adults

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DOI: 10.24327/ijrsr.2020.1101.5017

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 Available Online at http://www.recentscientific.com
International Journal of
CODEN: IJRSFP (USA)
Recent Scientific
International Journal of Recent Scientific Research Research
Vol. 11, Issue, 01(D), pp. 36885-36888, January, 2020
ISSN: 0976-3031 DOI: 10.24327/IJRSR
RESEARCH ARTICLE
REVIEWING THE PSYCHOMETRIC PROPERTIES AND FACTOR STRUCTURE OF THE
GENERALIZED ANXIETY DISORDER-7(GAD-7) IN A SAMPLE OF PUERTO RICAN
ADULTS
Orlando M. Pagán-Torres, Juan A. González-Rivera and Ernesto Rosario-Hernández
School of Behavioral and Brain Sciences, Ponce Health Sciences University
DOI: http://dx.doi.org/10.24327/ijrsr.2020.1101.5017

ARTICLE INFO ABSTRACT

Article History:
th
Received 12 October, 2019
Received in revised form 23rd
November, 2019
Accepted 7th December, 2019
Published online 28th January, 2020
Key Words:
anxiety, factor structure, GAD, Puerto
Rican, psychometric properties
Anxiety disorders may cause impairment in the functioning of daily life. This research aims to
examine the psychometric properties and factor structure of the Generalized Anxiety Disorder-7
(GAD-7) in a general sample of 302 Puerto Rican adults. We analyzed the Cronbach’s alpha internal
consistency, construct validity, discriminant validity, and factor structure of the instrument. The
findings of the study revealed that the GAD-7 obtained an excellent internal consistency of .92.
Pearson's r correlation analysis showed a high, positive, and statistically significant association
between GAD-7 providing evidence of concurrent validity. We conducted confirmatory factor
analyses to examine the factor structure of the GAD-7. The unidimensional model showed an
adequate adjustment to the data. The GAD-7 is an adequate instrument to measure anxiety
symptoms in Puerto Rico.

Copyright © Orlando M. Pagán-Torres et al, 2020, this is an open-access article distributed under the terms of the Creative
Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the
original work is properly cited.

INTRODUCTION Moreover, the Generalized Anxiety Disorder-7 (GAD-7) is a

According to the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5)1, the generalized anxiety disorder may
cause impairment in the functioning of daily life. The
proportion of the global population with anxiety disorders is
estimated to be 3.6% in 20152. A recent epidemiological study
conducted in Puerto Rico revealed that anxiety disorders are
the most common disorders affecting 12.5% of adults 18 to 64
years old3. Therefore, several anxiety measures have been used
to measure anxiety symptoms in Puerto Rico. Thus, Rodríguez-
Reynaldo et al.4evaluated the internal consistency of the Beck
Anxiety Inventory (BAI) with older adults, where the BAI
obtained a Cronbach’s alpha of .94. Fur thermore, González-
Barrios et al.5 evaluated the psychometric properties of the BAI
and the State-Trait Anxiety Inventory (STAI), with a sample of
80 subjects diagnosed with anxiety disorders and the BAI
obtained an internal consistency of .95 and the STAI of .93.
Moreover, González-Rivera et al.6 examined the factor
structure and the construct validity of the Depression, Anxiety,
and Stress Scales (DASS-21) with a sample of 1,073 Puerto
Rican adults. The results showed that the DASS-21 has serious
psychometric deficiencies, especially related to the construct
validity, as well as concurrent and discriminatory validity.
brief self-report measure of anxiety symptoms during the last
two weeks7, which is used frequently in Puerto Rico. The
English version revealed reliability coefficient of .927 and the
Spanish version a Cronbach’s alpha of .948. Besides, Millis et
al.9evaluated the reliability, structural validity, and concurrent
validity of the English and Spanish language versions of the
GAD-7 in 436 Hispanic Americans in the United States. The
findings revealed a reliability of .93 for the total sample, and an
one-factor structure model in Hispanics. In Puerto Rico, this
scale obtained an internal consistency of .9110. However,
literature review revealed that there is an absent of studies
dedicated to assessing the factor structure of the GAD-7 in a
Puerto Rican sample of adults. Therefore, this study has the
following objectives: (a) examine the factor structure of the
GAD-7 through confirmatory factor analyses (CFA) with the
maximum likelihood estimation in Puerto Rican adults; (b)
examine the reliability of the GAD-7 and item-total correlation;
and (c) examine concurrent validity with several anxiety-
related variables.

*Corresponding author: Orlando M. Pagán-Torres

School of Behavioral and Brain Sciences, Ponce Health Sciences University
Orlando M. Pagán-Torres et al., Reviewing the Psychometric Properties and Factor Structure of the Generalized Anxiety Disorder-7(Gad-7) in A Sample of Puerto
Rican Adults

METHOD original authors7, the total score may be categorized into four
severity groups: minimal (0-4), mild (5-9), moderate (10-14),
Research Design and Procedures and severe (14-20). The English version revealed reliability
The study was approved by the Institutional Review Board of.927and the Spanish version a Cronbach's alpha of .948. In
(IRB) of Ponce Health Sciences University, Ponce, Puerto Puerto Rico, this scale obtained an internal consistency of .9110.
Rico. The design used in current study was an instrumental Eight-Item Patient Health Questionnaire (PHQ-8): The PHQ-
one11,12. The recruitment of the participants was realized 8 (Spanish version) is an eight-item self-report measure that is
between April to June of 2019. For the recruitment of used to assess depression severity and criteria for a major
participants, the research was announced on several social depressive episode. Each item is rated in frequency on a 4-
networks such as Facebook and Whats App. We used the Psych point (0 = not at all, 3 = nearly every day) scale and total scores
Data platform to collect the participants electronically. The may range from 0 to 27. The authors13,14 suggest five levels of
research announcement redirected the participants to the online severity: minimal (total score, 0–4); mild (total score, 5–9);
survey. Participants read and completed the informed consent, moderate (total score, 10–14); moderately severe (total score,
which included information about the purpose of the study, 15–19); and severe (total score, 20–27). A score of 10 or above
inclusion/exclusion criteria, the voluntary nature to participate is frequently used as a cut point to identify patients with major
in the study, possible risks and benefits, and their right to depression. In a recent study, this scale obtained an internal
withdraw from the study at any time. No monetary consistency of .91 with a Puerto Rican sample15. In our study,
compensation was given to the participants. After all, subjects obtained an internal consistency of 88.
read the informed consent form. They were asked if they
agreed to participate in the study, and all those who accepted Post-traumatic Stress Disorder Scale for DSM-5 (PCL-5):
the terms were included in it. This is a self-report measure that evaluates the 20 symptoms of
PTSD-DSM-5. PCL-5 has a variety of purposes, including
Participants monitoring of the change of symptoms during and after
A non-probabilistic convenience sample technique was used to treatment, detection of people with PTSD, and making a
recruit the participants of the study. The total sample of the provisional diagnosis of PTSD16. It consists of 20 reagents
current study consisted of 302 participants. The sample average organized on a Likert-type scale that ranges from 0 Nothing to
age was 35.79 (DE = 12.14). The inclusion criteria to 4 Extremely. The possible range is 0 to 80 points, where the
participate in the study were: (1) be 21 years of age or older, higher the reported score, the higher the level of PTSD
(2) can read and understand Spanish, (3) be Puerto Rican and symptomatology. In a sample of Puerto Rican adults, this scale
(4) be a resident in Puerto Rico. Table 1 shows the full obtained a Cronbach's alpha of .96, and discrimination rates
sociodemographic characteristics of the subjects. were observed between .54 and .8917. In our study, obtained an
internal consistency of .95.
Table 1 Demographic Characteristics of the Sample
Data Analysis
Demographics F %
Sex In terms of statistical program for data analysis, we used IBM
Male 78 25.8 SPSS v.25 to calculate the sociodemo graphic characteristic of
Female 224 74.2
Marital Status the sample, internal consistency, and Pearson Coefficient
Single 148 49.0 Correlation to obtain concurrent validity. Then, we used
Married 102 33.8 STATA program18 to calculate the confirmatory factor
Widowed 3 1.0 analyses. We performed descriptive statistics, data distribution
Divorced 18 6.0
Cohabiting (free union) 31 10.3
analysis, item discrimination index, factor reliability analysis,
Annual Income (USD) and correlations among the total scores of the scales. We
$0–20,000 150 49.7 established the scales reliability using the Cronbach's alpha
$21,000–30,000 47 15.6 which have to be greater than .7019. Also, we conducted a
$31,000–40,000 34 11.3
$41,000–50,000 13 4.3
confirmatory factor analyses (CFA) with the maximum
$51,000–60,000 18 6.0 likelihood estimation method, and we used the Satorra-Bentler
$61,000 or more 40 13.2 adjustments, which is used when data is not normally
Academic Preparation distributed20. To examine how the proposed model adjust to the
High school or less 14 4.6
Associate degree/technical 13 4.3
data, we used Chi-square test (χ2sb), root mean square error of
Bachelor’s degree 84 27.8 approximation (RMSEAsb), Standardized Root Mean Square
Master’s degree 102 33.8 Residual (SRMR), Tucker–Lewis Index (TLIsb), and
Doctoral degree 89 29.5 Comparative Fit Index (CFIsb). Values of RMSEAsb less than
Generalized Anxiety Disorder-7 (GAD-7). The GAD-7 .08 and SRMR values less than .05 are indicative of an
questionnaire (Spanish version) is a one-dimensional self- adequate adjustment of the model21. Meanwhile, CFIsb and
administered scale designed to assess the presence of the TLIsb values higher than .90 represent acceptable adjustment of
symptoms of Generalized Anxiety Disorder, as listed in the the model21. Also, we considered the regression coefficients of
DSM-IV. The total GAD-7 score is calculated by the simple each item on its respective factor, which should exceed .5022 to
addition of the answers to each item. Each item is rated in be considered adequate.
frequency on a 4-point (0 = not at all, 3 = nearly every day)
scale and total scores may range from 0 to 21. According to the

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 International Journal of Recent Scientific Research Vol. 11, Issue, 01(D), pp. 36885-36888, January, 2020

RESULTS DISCUSSION
An analysis of confirmatory factors using structural equations The purpose of this study was to examine the factor structure of
was carried out. The tested model was confirmed by only one the GAD-7, examine its reliability through Cronbach’s alpha
latent factor, which clustered the seven items of the GAD-7 internal consistency, item-total correlations, and the concurrent
(see Figure 1). The results cast a good adjustment for the validity in a sample of Puerto Rican adults. The results
model with the corresponding releases between errors and the revealed that the unidimensional model examined in the CFA
corrections of Satorra and Bentler20, χ2SB = 54.49 (14) p< .001, obtained adequate adjustment to the data. This one-factor
RMSEASB = .06, CFISB = .98, TLISB = .97. All items reflected model is consistent with the original model proposed by the
regression coefficients greater than .50. The discrimination authors7. Moreover, our results revealed that GAD-7 obtained
indexes of the GAD-7 were examined through an item-total an excellent Cronbach’s alpha (.92). Furthermore, we found a
correlation index (rbis). All items obtained discrimination statistically significant association between the GAD-7 with the
indexes greater than .30. Table 2 displays the discrimination PHQ-8 and the PCL-5, which implies a good concurrent
indexes and the regression coefficients in the confirmatory validity. Therefore, we have a brief self-report measure, easy to
factorial analysis and the corresponding confidence intervals. administer and understand, and excellent psychometric
The seven items were submitted to an internal consistency properties to be used with Puerto Rican. Consequently, this
analysis to determine the scale reliability index. The results study provides valuable and innovative information to the
illustrate an Alpha coefficient of .92 and .87 for the Spearman- scientific community about GAD-7 as an alternative and
Brown test. Finally, Pearson's r correlation analysis showed plausible brief measure for anxiety symptoms in the Puerto
that GAD-7 correlated positively and significantly with PHQ-8 Rican population.
(r = .74, p<.001) and with PCL-5 (r = .75, p<.001), providing
The GAD-7 may be used in a clinical and research context with
evidence of concurrent validity.
clinical (outpatient and inpatient) and non-clinical samples. In
the clinical setting, this measure may be used as a tool for
screening anxiety symptoms with an excellent precision where
the interventions consist of a brief time. This is a limitation for
other depressive measures that are more extensive such as the
BAI (21 items). Moreover, from a research perspective, this
measure may be used in any kind of study that involves the
exploration of anxiety symptoms. Another advantage of this
measure is that it provides the opportunity to administer
simultaneously with a battery of psychological measures (for
clinical or research purposes) in order to explore additional
constructs that are positively or negatively associated with
anxiety.
Moreover, this study has several limitations. First, the study
participants were not randomly recruited; therefore, it is not
considered a representative sample of adults from the Puerto
Rican population. Second, we do not evaluate the reliability of
the instrument over time (using test-retest strategy). Finally, the
recruitment of our study was obtained electronically, which
means that this kind of recruitment may affect the study means
and increase the standard error. However, digital recruitment
allowed us to amply the diversity of the sample in terms of
sociodemographic characteristics and sample size. However,
we used advanced statistical techniques and adequate sample
size in order to provide empirical strength to our results.
Figure 1 Unidimensional Model of the GAD-7. Despite the limitations mentioned in our study, the results
provide relevant and preliminary information about the
Table 2 Descriptive and statistical analysis of the items
psychometric properties and factor structure of the GAD-7 with
Items rbis Β p C.I. 95% a Puerto Rican sample. Therefore, we recommend future
GAD-1 .75 .80 .00 [.74 - .86] research directed to examine the psychometric properties and
GAD -2 .84 .90 .00 [.86 - .94]
GAD -3 .81 .88 .00 [.84 - .91] factor structure of the GAD-7 with specific samples such as
GAD -4 .79 .83 .00 [.75 - .88] ethnic minority samples and outpatients/inpatients samples in
GAD -5 .64 .64 .00 [.54 - .74] Puerto Rico.
GAD -6 .68 .70 .00 [.62 - .77]
GAD -7 .68 .68 .00 [.59 - .77] CONCLUSIONS
Note: rbis = Discrimination Index; β = Standardized regression coefficients; p = The findings of this study revealed that GAD-7 has excellent
significance; C.I. 95% = confidence intervals of the regression coefficients.
psychometric properties and reply the unidimensional factor
structure with a sample of Puerto Rican adults. These results
are consistent with other findings documented among

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Orlando M. Pagán-Torres et al., Reviewing the Psychometric Properties and Factor Structure of the Generalized Anxiety Disorder-7(Gad-7) in A Sample of Puerto
Rican Adults
Hispanics9. Therefore, the GAD-7 is a reliable and valid
measure, easy to administer that may be used in any research
and/or clinical setting to explore the manifestations of the
anxiety symptoms.
References
1. American Psychiatric Association. Diagnostic and
statistical manual of mental disorders (5th ed.). Author:
Washington, DC; 2010.
2. World Health Organization. Depression and other
common mental disorders global health estimates. 2017.
Retrieved by
https://apps.who.int/iris/bitstream/handle/10665/254610/
WHO-MSD-MER-2017.2-eng.pdf
3. Canino G, Vila D, Santiago-Batista, K et al. Need
assessment study of mental health and substance use
disorders and service utilization among adult population
of Puerto Rico. Behavioral Sciences Research Institute;
2016. Available online: http://www.assmca.pr.gov/
4. Rodríguez-Reynaldo M, Martínez-Lugo M, Rodríguez
Gómez, J. Estudio de las características psicométricas
del Inventario de Ansiedad Beck (en castellano) en una
muestra de envejecidos puertorriqueños. Rev Esp Geriatr
Gerontol. 2001; 36: 353-60.
5. González-Barrios P, Morales-Rodríguez C, Merced-
Morales Ket al.Dimensional assessment of anxiety in
Puerto Rican patients: evaluating applicability of
psychological questionnaires. P R Health Sci J. 2016;
35: 134-41.
6. González-Rivera JA, Pagán-Torres OM, Pérez-Torres
EM. Depression, Anxiety and Stress Scales (DASS-21):
Construct validity problem in Hispanics. European
Journal of Investigation in Health, Psychology and
Education. 2020; 10: 375-89.
7. Spitzer RL, Kroenke K, Williams JB et al. A brief
measure for assessing generalized anxiety disorder: the
GAD-7. Arch Intern Med. 2006;166: 1092- 97.
8. García-Campayo J, Zamorano E, Ruiz, MA et al.
Cultural Adaptation into Spanish of the Generalized
Anxiety Disorder-7 (GAD-7) Scale as a screening tool.
Health Qual Life Out. 2010; 8: 1-11.
9. Mills SD, Fox RS, Malcarne VL et al. The psychometric
properties of the Generalized Anxiety Disorder-7 Scale
in Hispanic Americans with English or Spanish language
preference. 2014. Cultur Divers Ethnic Minor Psychol;
20: 463–468.
How to cite this article:
Orlando M. Pagán-Torres et al.2020, Reviewing the Psychometric Properties and Factor Structure of the Generalized Anxiety
Disorder-7(Gad-7) in A Sample of Puerto Rican Adults. Int J Recent Sci Res. 11(01), pp. 36885-36888.
DOI: http://dx.doi.org/10.24327/ijrsr.2020.1101.5017
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10. Morales-Cruz J, Bernal G, Amaral-Figueroa M. Impacto
y viabilidad de una intervención con activación
conductual mediante actividad física para sobrevivientes
de cáncer de mama. Rev Puertorriquena Psicol. 2017;
28: 116-32
11. Ato M, López JJ, Benavente A. Un sistema de
clasificación de los diseños de investigación en
psicología. An Psicol. 2013. 29: 1038-59.
12. Montero I, León OG. A guide for naming research
studies in psychology. Int J Clin Hlth Psyc. 2007. 7:
847-62.
13. Kroenke K, Spitzer RL, WilliamsJB. The PHQ-9:
validity of a brief depression severity measure. J Gen
Intern Med. 2001; 16: 606-13.
14. Kroenke K, Strine TW, Spitzer RL et al. The PHQ-8 as a
measure of current depression in the general population.
J Affect Disord. 2009; 114: 163-73.
15. González-Rivera, J.A. Validation and dimensionality of
Patient Health Questionnaire for depression (PHQ-8 and
PHQ-9) in Hispanic LGTB+ Community. International
Int J Recent Sci Res. 2019; 10: 36670-6.
16. Blevins CA, Weathers FW, Davis MTet al. The
Posttraumatic Stress Disorder Checklist for DSM-5
(PCL-5): Development and Initial Psychometric
Evaluation. J Trauma Stress. 2014; 28: 489-98.
17. García A. Sintomatología de trastorno por estrés
postraumático en adultos puertorriqueños (Thesis).
Universidad Carlos Albizu: Puerto Rico; 2018.
18. Stata Corp. Stata: Release 15. Statistical Software. Stata
Corp LLC: Texas; 2017.
19. DeVellis RF. Scale development: Theory and
applications. Sage: California; 2017.
20. Satorra A, Bentler PM. A scaled difference chi-square
test statistic for moment structure analysis.
Psychometrika. 2001; 66: 507-14.
21. Byrne BM. Structural equation modeling with AMOS:
Basic concepts, applications, and programming.
Psychology Press: New York; 2010.
22. Hair JF, Black WC, Babin, B.J et al. Multivariate Data
Analysis, 6a. ed.; Prentice-Hall International: New
Jersey; 2006.
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