Psychometric Properties of the Arabic Translation of the Psy-Flex Scale in Adolescents

doi:10.21203/rs.3.rs-5267794/v1

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Psychometric Properties of the Arabic Translation of the Psy-Flex Scale in Adolescents

https://doi.org/10.21203/rs.3.rs-5267794/v1

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Background

Psychologic flexibility, integral to mental wellbeing, has gained popularity for its role in fostering adaptive coping mechanisms. However, research on this subject in the Middle Eastern population, particularly among adolescents, is limited. This study aimed to examine the psychometric properties of an Arabic translation of the Psy-Flex Scale in a sample of Lebanese adolescents.

Methods

Using a cross-sectional design, 793 adolescents form all districts/governorates participated in the study conducted in November 2023 using a snowball sampling technique. The Psy-Flex Scale and the Depression Anxiety Stress Scale were used in this study.

Results

Confirmatory Factor Analysis results indicated that the fit of the one-factor model of the Psy-Flex Scale was modest: RMSEA = .109 (90% CI .090, .130), SRMR = .039, CFI = .948, TLI = .914. The modification index between items 3 and 6 was high; after adding a correlation between those residuals, the fit indices improved: RMSEA = .089 (90% CI .069, .112), SRMR = .033, CFI = .969, TLI = .942. The composite reliability of scores was adequate in the total sample (ω = .84 / α = .84). We were able to show the invariance across sex at the configural, metric, and scalar levels. No significant difference was seen between males and females in terms of psychological flexibility scores (17.91 ± 4.90 vs 17.40 ± 4.34; t(791) = 1.50; p = .134). Concurrent validity was shown since higher psychological flexibility was significantly associated with lower depression (r = − .08; p = .024) and lower anxiety (r = − .10; p = .004), but not stress (r = .06; p = .090).

Conclusion

The validation of the Arabic Psy-Flex Scale represents a significant contribution to Arab mental health research, providing a culturally sensitive tool to assess psychological flexibility in adolescents and explore its associations with psychological distress.

Psy-Flex Scale

Psychologic flexibility

Adolescence

Psychometric properties

Arabic

Psychologic flexibility, deemed integral to mental wellbeing, has recently surged within the field of psychology for its role in fostering adaptive coping mechanisms and resilience in confronting contemporary life’s challenges (Kashdan & Rottenberg, 2010a). Originally derived from the Acceptance and Commitment therapy (ACT), the concept of psychological flexibility involves acceptance and tolerance of emotions and thoughts without judgment while choosing behaviours that are in concordance with one’s values and long-term goals (Hayes et al., 2011) Thus, ACT enhances psychological flexibility; whereas a diminished capacity for the latter might be the root cause of the suffering experienced in psychiatric disorders such such as anxiety and depression, and chronic illnesses (Fledderus et al., 2013).

Different scales to evaluate the concept of psychological flexibility have been developed. Several self-reported questionnaires have been used to evaluate the psychological flexibility including the Acceptance and Action Questionnaire (AAQ-II) (Bond et al., 2011a), as well as the Multidimensional Psychological Flexibility Scale (Rogge, 2016). The Psy-Flex was created by Gloster et al. in 2021(Gloster et al., 2021a), distinguished by its simplicity, efficiency and robust psychometric properties as it consists of six distinct items referring to the person’s experience in the last seven days such as being present, being open for experiences, being engaged, leaving thoughts be, steady self, and awareness of one’s value (Gloster et al., 2021a). It is relevant to add that the AAQ-I and AAQ-II has been criticised for a poor internal consistency and divergent validity as well as questionable factor structure (Bond et al., 2011b). The main issue encountered with this questionnaire is its tendency to rely on negative emotionality, rather than with PF (Wolgast, 2014). In contrast with AAQ-II that was strongly associated with symptomatology and a tool to measure distress, Psy-Flex was proven to be a tool correlated with mindfulness, meaning of life and well-being. Previous studies demonstrated the importance of Psy-Flex as a predictor for variance in well-being.(Gloster et al., 2011)

The conception of the Psy-Flex scale was based on previously developed questionnaires as a starting point. This was then moulded to better encompass specific emotions by several ACT experts with a plethora of experience in the field.(Gloster et al., 2021b)

Nothing that the well-constructed questionnaire reduces the burden of the response and increase reliability. In addition, the Psy-Flex Scale exhibited validity in diverse cultural settings such as Korea(Jo et al., 2023), Portugal (Soares et al., 2023), and Turkey (Yıldırım & Aziz, 2023). Broadly, these validation studies as well as the original study have supported invariance of scores when comparing the genders (Gloster et al., 2017; Jo et al., 2023; Yıldırım & Aziz, 2023), as well as a satisfactory composite reliability and factor structure. Additionally, the original study showed a one-factor construct with impressive reliability (Raykov’s r = 0.91) (Gloster et al., 2017; Raykov, 2001)

Psychological flexibility can vary between cultures due to differences in values, norms, and beliefs(Kashdan & Rottenberg, 2010b) In acceptance and commitment therapy skills book by Luoma et al., the authors discuss how the core principles of ACT are not tied to a specific cultural value system but rather encourages people to explore their own values with regard to their social backgrounds (Luoma et al., 2007)

The present study

In the Middle Eastern population in particular, research regarding psychological flexibility is limited. Mental health stigma is prevalent in Arab communities due to misconception and unawareness about mental illness which in turn influence health outcomes and call for the need of reliable and valid assessment tools (Maalouf et al., 2019)

Meta-analysis estimated that psychological flexibility was a crucial factor for upholding a stable mental health. The Arab world is home to approximately 5% of the world’s population, with mental health disorders attributed as the ninth most relevant cause of disease burden (Charara et al., 2018). Specific to Lebanon (Regan et al., n.d.) it has been shown that although the Lebanese population possesses average mental health knowledge and a high attitude score (Obeid et al., 2020), it has certain stigmatizing attitudes toward mental health illnesses(Regan et al., n.d.). Furthermore, adolescents in Lebanon are an especially sensitive age group, with more than 62% suffering from mild-to-moderate depression(Dagher et al., 2023) affecting their psychological flexibility. Additionally, the Lebanese population have been submitted to multiple life-changing events such as the War in 2006, the recent COVID-19 pandemic and the unfortunate explosion that occurred at Beirut’s port as well as the economic crisis on top of the rising inflation which all lead to deteriorating the basic human necessities, leading to an increase in anxiety.

Moreover, the Lebanese population has been subjected to a serious of profoundly distressing events, including the significant impact of the COVID-19 pandemic in 2020, the devastating explosion at Beirut’s Port - the largest non-nuclear explosion in history, and the persistent economic crisis threatening essential human needs. These events have directly and indirectly contributed to heightened levels of death anxiety among Lebanese (Farran, 2021). All these factors are affecting the mental health of Lebanese people affecting negatively their mental health and subsequently their psychological flexibility. Since Psychological flexibility is considered a buffer facing psychological distress, individuals with PF are better suited to accept inevitability and unpredictability of the situation and are better suited to pursue measurable goals during a pandemic.(“Supplemental Material for Understanding Psychological Flexibility: A Multimethod Exploration of Pursuing Valued Goals Despite the Presence of Distress,” 2020) A correlation between lower COVID-19 related distress and psychological flexibility was demonstrated by Dawson et al.(Dawson & Golijani-Moghaddam, 2020)

Consequently, the mental well-being experienced during adolescence significantly affects mental health in adulthood (Yousefi Afrashteh & Hasani, 2022) Adolescence is a period of growth at the core of identity and emotional development related to psychological flexibility (Kukkola et al., 2023) Teenagers experience shifts in their cognitive abilities, biological and physical maturation in addition to interpersonal connections (Denham et al., 2009) Additionally, they are tasked with making radical life decisions which can elicit anxiety and affective instability (Puolakanaho et al., 2023)

Currently, there is a notable rise in mental health concerns particularly in young adults and adolescents. In fact, the necessity for an enhanced comprehension of the correlation of psychological flexibility and psychological distress, focusing on this age group, is growing(Daks et al., 2020) Therefore, our findings aimed to assess the psychometric properties of an Arabic translation of the Psy-Flex Scale. We hypothesized that an Arabic version of the Psy-Flex Scale will: (1) reproduce similar results to the original study’s one-factor structure, (2) demonstrate gender invariance and acceptable composite reliability, and (3) determine an suitable correlation using Psy-Flex scale and psychological distress.

Ethics Approval and Consent to Participate. The Lebanese International University's School of Pharmacy ethics committee granted this study ethics permission (2023RC-033-LIUSOP). When filling out the online form, each participant provided written informed consent, as did their parents or legal guardian(s) if they were study participants under the age of sixteen. Every step of the process was carried out in compliance with all applicable laws and rules (in accordance with the Declaration of Helsinki).

Procedure

In November 2023, a sample was collected from the different governates of Lebanon in order to complete this cross-sectional study. Through the snowball technique, the survey was filled out utilizing different messaging and social media platforms: e.g. Instagram, Facebook Messenger, and WhatsApp). A virtual informed consent form was created through “Google Forms” before filling out the questionnaire, informing the participants of the aim of the study, and guaranteeing their anonymity. This form was to be signed after it was read thoroughly, before filling any of the questionnaire’s questions by ticking a box stating: “Yes, I acknowledge having read the above-mentioned information and I agree to participate in this study voluntarily and without any pressure”. After proceeding with the digital informed consent, the questionnaire’s items are given in a pre-randomized order, to reduce any order effects. No financial benefit was provided and the participants were able to either accept or refuse to fill this form.

Translation Procedure

Firstly the Psy-Flex Scale was translated and adapted into the Arabic language and context, then it was implemented into our study. This required the PFS to be rendered into literary Arabic, which is the modern Standard Arabic, the current official language across the Arab countries employed for cross-group communication. The main aim was to achieve a similar semantic between the original and the Arabic-translated version, all in all, to be in accord with the international recommendations and norms (Weeden & Poling, 2010). A forward and backward translation methodology was utilized to execute this translation. The questionnaire was translated by a Lebanese translator, who was not affiliated with either this study or the affiliated parties, from the English version to Arabic. Later on, the findings were translated back from Arabic to English by a Lebanese psychologist who is skilled in English. Additionally, the translation team ensured a smooth and balanced process, addressing either specific or literal translations. Also, a specialized committee that included two psychiatrists, a psychologist, and the aforementioned research team as well as two sworn translators, ensured to identify and correct any possible inconsistencies in contrast to the initial and translated English versions. (Kashdan & Rottenberg, 2010b) Potential misunderstandings in the phrasing and wording of the items were closely reviewed to enhance the ease of item interpretation and for a better contextual adaptation. (Koenig et al., 2012) After completing the translation and retooling, thirty participants were involved in a pilot study that was conducted to reinforce the comprehension of the items/questions. After the completion of the study, no changes were made, concurring the clarity and comprehension of the translated scale.

Measures

Similarly to the original English questionnaire, this Arabic questionnaire evaluated the sociodemographic characteristics of this study’s sample (including age and sex), as well as the following scales

Psy-Flex Scale: it consists of six items that emphasize the skills tackled in the ACT for cultivating psychological flexibility in order to enhance the patient’s well-being. (Gloster et al., 2021a) The phrasing is tailored to be contextually relevant, and the formulation of the items focuses on the presence of a specific ability (“e.g. being present or being open to new experiences”) rather than its absence. (Gloster et al., 2021a) The members of the study evaluate each item on a scale that ranges from 1 “very seldom” to 5 “very often” and then this score is summed for interpretation. Higher scores indicate higher psychological flexibility.

Depression Anxiety Stress Scale (DASS-8). Validated in Arabic, this scale consists of eight different items that are subdivided into three subscales: anxiety (which consists of 3 items: “e.g. I felt scared without any good reason”), depression (which consists of 3 items as well: “e.g. I was unable to become enthusiastic about anything”) and finally stress (which consists of 2 items: “e.g. I felt that I was using a lot of nervous energy”). (Peng et al., 2021) Answers to this scale are rated on a 4-point measure, starting from 0 (did not apply to me at all) to 3 (applied to me most of the time or very much). This score for DASS-8 ranges from 0 to 24, subdivided into 3 subscales, 0 to 9, 0 to 9, and 0 to 6 respectively. Scoring higher is equivalent to a better level of symptom affirmation. This resulted in the following coefficients: depression (ω = .75 / α = .75), anxiety (ω = .77 / α = .77), stress (α = .58).

Analytic Strategy

Confirmatory factor analysis. No missing responses were reported in our dataset. We utilized data from our total sample to initiate a CFA using the SPSS AMOS v.29 software. We aimed to include a minimum of 120 adolescents according to the recommendations of Mundform et al. of 3 to 20 times the number of the scale variables (Mundfrom et al., 2005). Parameter estimates were acquired employing the maximum likelihood method. “A multitude of fit indices were taken into account: Steiger-Lind root mean square error of approximation (RMSEA), standardized root means square residual (SRMR), Tucker-Lewis Index 9TLI), and Comparative Fit Index (CFI). Achieving ≤ .08 for RMSEA, ≤ .05 for SRMR and ≥ .90 for CFI and TLI is correlated with a good fit of the model to the data (Hu & Bentler, 1999)” Additionally, a target of Average variance extracted (AVE) reaching ≥ .50 is indicative of adequate convergent validity. Since multivariate normality was not proved initially (Bollen-Stine bootstrap p=0.02); we accomplished a non-parametric bootstrapping procedure (Azzi et al., 2023; Fekih-Romdhane et al., 2023; Swami et al., 2022)

Sex invariance. In order to evaluate the gender invariance of the Psy-Flex scores, a multi-group CFA was conducted using our total sample. (Chen, 2007). Measurement invariance was assessed at the configural, metric, and scalar levels. As evidence of invariance, we accept a ΔCFI ≤ .010 and ΔRMSEA ≤ .015 or ΔSRMR ≤ .010 (Swami et al., 2022)

Further analyses. Composite reliability was assessed using McDonald’s ω and Cronbach’s α, with values greater than .70 reflecting adequate composite reliability (Dunn et al., 2014). Normality was confirmed: skewness and kurtosis values varied between -1 and +1 for each item that was found on the scale (Hair Jr et al., 2023). Student t-test was also applied to compare two means. Finally, an additional test was used, the Pearson test, to compare the scores with different scales in the survey.

Participants

Seven hundred ninety-three adolescents participated in our study. Their mean age was of 16.08 ± 1.74 years and 62.4 % were females.

Confirmatory Factor Analysis of the Psy-Flex Scale

CFA indicated that the fit of the one-factor model of the Psy-Flex Scale was modest: RMSEA = .109 (90% CI .090, .130), SRMR = .039, CFI = .948, TLI = .914. The modification index between items 3 and 6 was high; after adding a correlation between those residuals, the fit indices improved: RMSEA = .089 (90% CI .069, .112), SRMR = .033, CFI = .969, TLI = .942. The standardized estimates of factor loadings were all adequate (Figure 1). The composite reliability of scores was adequate in the total sample (ω = .84 / α = .84). The convergent validity for this model was borderline, as AVE = .48.

Sex Invariance

Through our findings were able to demonstrate invariance across sex at multiple levels: configural, scalar, and metric levels (Table 1). According to psychological flexibility scores, no significant difference was observed between males and females (17.91 ± 4.90 vs 17.40 ± 4.34; t(791) = 1.50; p = .134).

Table 1. Measurement Invariance of the Psy-Flex Scale across sex in the total sample.

Model	CFI	RMSEA	SRMR	Model Comparison	ΔCFI	ΔRMSEA	ΔSRMR
Configural	.954	.078	.045
Metric	.953	.069	.046	Configural vs metric	.001	.009	.001
Scalar	.952	.062	.046	Metric vs scalar	.001	.007	<.001

Note. CFI = Comparative fit index; RMSEA = Steiger-Lind root mean square error of approximation; SRMR = Standardised root mean square residual.

Concurrent validity

Higher psychological flexibility was significantly associated with lower depression (r(793) = -.08; p = .024) and lower anxiety (r(793) = -.10; p = .004), but not stress (r(793) = .06; p = .090).

The goal of our findings was to translate, adapt, and validate the Psy-Flex Scale into an Arabic version within a population of adolescents from average Lebanese population. Our findings indicate that our iteration of the scale maintains fidelity to its original factorial framework based on several indices such as RMSEA <0.8, SRMR<0.5, CFI and TLI of >0.90 (Gloster et al., 2021a)

In order to complete our analysis, we aimed to determine the fitting factor structures of scores of the Arabic-translated Psy-Flex Scale. In order to achieve that, we utilised the best-practice recommendations in adopting the confirmatory factor analysis. This single-factor structure was then testified by using an Arab community sample, and depicting measurement invariance across sex. Considering that the original Psy-Flex study (Gloster et al., 2021a) was unidimensional, our CFA results suggested that single-factor structure, after correlating the residuals of items 3 through 6, was in support of the original study’s theory. Although we had different populations (European and Korean)(Jo et al., 2023) vs this study (Arab) it is possible that the 6 items measured represent a singular construct of psychological flexibility across multiple cultural environments.

Sex invariant analysis showed no substantial differences between female and male adolescents using Psy-Flex Scale suggesting that sex does not influence individuals’ scores on the scale. Configural, metric, and scalar invariance were established, indicating that the underlying structure, factor loadings and items of the scale are equivalent across sex reflecting its applicability and validity in diverse populations. Previous studies have demonstrated similar findings to our study, supporting the gender invariance with no significant differences between male and female candidates [7], [8]. On one hand, the Korean and the Turkish validation studies found that only partial scalar invariance was supported across the two genders, theorizing that the scale would not have the same meaning to men and women (focusing especially on item 5) (Jo et al., 2023; Yıldırım & Aziz, 2023). On the other hand, the Portuguese-translated scale determined that men have a higher psychological flexibility in comparison to women in contrary to our findings and the findings of Gloster’s paper (Gloster et al., 2017; Soares et al., 2023). The original study had mixed results concerning this topic: different samples with different outcomes and correlations as it pertains to gender (Gloster et al., 2021a) This variety in results could be the results of different genders adhering to different social and gender norms, which could in turn influence on psychological response of different individuals and their decision making. This matter, however, should be a starting point to kickstart further research, focusing on the qualitative measures that could reveal the intricacies in which gender is contrasted with psychological flexibility, especially in adolescents.

At the level of internal consistency, notable similarities and differences emerge when juxtaposed with validations conducted in Turkish(Yıldırım & Aziz, 2023) (Cronbach's α = .80), Korean(Jo et al., 2023) (Cronbach's α = .92), and Portuguese (Cronbach's α = .82) populations(Soares et al., 2023). Our study revealed comparable robust internal consistency (ω = .84 / α = .84), echoing the high levels observed in the Korean validation (Cronbach's α = .92, McDonald's ω = .96)(Jo et al., 2023) thus affirming the Psy-Flex scale’s replicability across diverse cultural settings. Similarly to the Turkish validation, our research underwent a rigorous process of model refinement through confirmatory factor analysis, leading to enhancements in fit indices and optimizing scale performance. We found an internal consistency, measured by Cronbach’s alpha, of 0.74 (Yıldırım & Aziz, 2023) Conversely, our study recommended thresholds, contrasting with the robust psychometric properties observed in other validations, notably the Portuguese study, which emphasized exceptional fit indices without explicitly addressing the AVE. In the total sample of 700 Portuguese participant, the internal consistency was established to be 0.82 (Trindade et al., 2022).

Regarding the correlation between psychological flexibility and outcomes of the mental health, higher psychological flexibility was associated with lower depression and anxiety among adolescents, which aligns with existing literature suggesting that psychological flexibility serves as a bugger against negative outcomes on the mental health (Trindade et al., 2020; Wang et al., 2023). However, we should note that the correlation coefficients were small, therefore, the results should be interpreted with caution.

A Japanese paper by Kato investigates how the psychological inflexibility negatively impacts depressive symptoms and sleep quality, recognizing the potential interplay between mental health and sleep patterns (Kato, 2016) Another article by Yao et al. conducts a comprehensive meta-analytic review to explore the correlation of mental health challenges and the psychological flexibility during the COVID-19 era. During this period, by synthesizing data from multiple studies at three different levels of analysis, the research provides a nuanced understanding of how psychological flexibility impacts mental health (Yao et al., 2023) The findings offer valuable insights into the potential protective role of psychological flexibility and its implications for promoting resilience and well-being in the face of adversity (Daks et al., 2020)

A paper by Warsebe et al. using an ACT intervention investigating the association between stress, well-being and psychological flexibility and found that a collective rise in psychological flexibility throughout the intervention lead to a reduction in stress and increase in well-being (Wersebe et al., 2018) Furthermore, people with higher psychological flexibility have a reduced propensity for being engaged in unwanted cognitive patterns such as rumination, displaying less avoidance of emotional or unwanted thoughts, thus tend to experience lower levels of experienced stress (Cyniak-Cieciura, 2021)

In the Arab region, adolescents face additional stressors related to socio-political instability, economic uncertainty, and cultural expectations, which may impact their psychological well-being and resilience furthermore (Alkaid Albqoor et al., 2023)

Clinical Implications

The translation of the PFS into Arabic and the validation within a sample of adolescents in the region represent a significant contributor to the Arab mental health research. The validation of the Arabic Psy-Flex Scale opens new avenues in adolescent mental health, especially in the Arab region. Researchers can now utilize this validated measure to investigate the correlates and predictors of psychological flexibility among this population, explore its associations with various mental health outcomes, and evaluate the effectiveness of interventions aimed at promoting adaptive coping skills and resilience.

Limitations

A plethora of limitations should be acknowledged when analysing our findings of this validation study. Firstly, while efforts were made to ensure the linguistic and cultural equivalence of the translated PFS, it is essential to recognize that language and cultural nuances may influence the interpretation of scale items and responses. Variations in dialects, idiomatic expressions, and cultural norms across different regions of the Arab world may impact the psychometric properties of the measure and should be considered in future research. Furthermore, this research was limited by its cross-sectional design since reporting bias is present due to self-reported data and the over-representation of female participants. Additionally, the sample was collected exclusively in Lebanon, resulting in a poor generalizability of our results in the Arab population. In order to surpass these limitations, further studies should englobe a more representative sample of Arab population, including minorities as well as different sexual orientation and to implement longitudinal and cross-cultural approaches. Furthermore, evidently the fact that this study was collected online may have an impact on the validity of the results, in comparison with a more hands-on face to face or pen and paper method. Finally, convergent validity and test-retest reliability were not evaluated.

To conclude, the validation of the translation of the Psy-Flex Scale to Arabic in a sample englobing Lebanese adolescents represents a significant advancement in Arab mental health research. Through meticulous translation procedures and confirmatory factor analysis, the Arabic Psy-Flex Scale demonstrated strong psychometric properties including good fit indices, adequate internal consistency, and sex invariances. While acknowledging limitations in linguistic and cultural equivalence and sample representation, the validation of the Arabic Psy-Flex Scale opens new avenues for understanding and promoting adaptive coping skills and resilience among Arab adolescents.

Consent for publication: Not applicable.

Availability of data and materials: Because of ethical committee constraints, none of the data collected or analyzed during this study are publicly available. However, the corresponding author (SH) may make the data available upon reasonable request.

Competing interests: The authors have nothing to disclose.

Funding: None.

Author contributions: S.O, F.F.R and S.H designed the study; MT and REM drafted the manuscript; SH carried out the analysis and interpreted the results; F.S and M.D collected the data. D.M reviewed the paper for intellectual content; all authors reviewed the final manuscript and gave their consent.

Clinical trial number: Not applicable.

Acknowledgements: The authors would like to thank all participants.

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Psychometric Properties of the Arabic Translation of the Psy-Flex Scale in Adolescents

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