ARTICLES

Utility of the Beck Anxiety Inventory AmongGhanaians: a Preliminary Study

Kofi Krafona

# Springer Science+Business Media New York 2013

Abstract The Beck Anxiety Inventory (BAI) is a well-known clinical tool forscreening anxiety. A number of researches has indicated its utility in a wide range ofclient groups including adolescents and people with intellectual disability. Its useamong predominantly black population in a non-western world, however, is not well-documented. The study set out to examine its psychometric properties amongundergraduate students in Ghana. There were 133 participants consisting of 86 malesand 47 females with a mean age of 23.83 years (SD=3.21) who volunteered. Theresults showed that the full scale mean score was 17.65 (SD=12.72) with no significantdifference between the males and females (t (131)=.05, p>.05, two-tailed). TheCronbach coefficient alpha was .93. The four-factor structure was not supported,instead a three-factor structure consisting of autonomic, somatic, and fear/panicelements was revealed. The correlations between the factors were moderate rangingfrom .51 to .65. In general, the BAI may be potentially useful as a research tool inGhana. A number of limitations have been pointed out and future work is required toestablish its research and clinical utility in Ghana.

Keywords Anxiety . BeckAnxiety Inventory . Predominantly black population

Introduction

In both clinical and non-clinical populations, the Beck Anxiety Inventory (BAI) hasbeen found to be useful not least because of its ability to measure cognitive and somaticaspects of anxiety (Beck et al. 1988; Kumar et al. 1993; Morin et al. 1999; Osman et al.1997). At least two (Beck et al. 1988) or more (Morin et al. 1999; Osman et al. 1997;Creamer et al. 1995) factor structures have been identified by researchers inpredominantly Caucasian cultures compared to ethnic minority or other non-Caucasian cultures (Contreras et al. 2004). The BAI has excellent internal consistency

J Afr Am StDOI 10.1007/s12111-013-9271-4

K. Krafona (*)Department of Educational Foundations, University of Cape Coast, Cape Coast, Ghanae-mail: krafikof@gmail.com

with psychiatric outpatients (alpha=.92, Beck et al. 1988; alpha=.94, Fydrich et al.1992; alpha=.90, Kabacoff et al. 1997).

Beck et al.’s (1988) factor structure was performed using exploratory factor analysiswith oblique promax rotation. This revealed two factors labeled as somatic(physiological) and cognitive (subjective anxiety and panic). These two factorscorrelated moderately and positively (r=.56). Other two factor structures includestudies by Contreras et al. (2004) in which 2,703 Caucasian American and 1,110Latino college students were involved. Exploratory factor analysis with promaxrotation was used, and it was reported that internal consistency was good withcoefficient alpha exceeding .82. It was also reported that scores for the Latino studentswere significantly higher than Caucasian American students on total scores and womenscored significantly higher than men. Kumar et al. (1993) also investigated thedimensions of the BAI among 108 adolescent psychiatric in-patients who had differenttypes of psychiatric disorders. Their ages ranged between 12 and 17 years old. Using aniterated principal-factor analysis, they identified factors representing subjective andsomatic symptoms of anxiety.

On the other hand, more than two factors have also been identified by someresearchers. For example, Osman et al. (2002) identified four factors in theirstudy whose participants included adolescent psychiatric inpatients (N=240)and non-clinical high school students (N=167). Both samples had a mixture ofEuropean–Americans, African-Americans, Latinos/Hispanics, and other ethnicgroups. The identified factors were neurophysiological, subjective, autonomic,and panic factors. The factors had moderate intercorrelations (ranging from.31 to .55).

A six-factor solution has been identified by Morin et al. (1999). They used a non-clinical sample of 281 older adults. Exploratory factor analysis (principal axisfactoring) with orthogonal (varimax) rotation was used. An alpha coefficient of .89was reported, and the factors identified were somatic (six items), fear (three items),autonomic hyperactivity (three items), panic (four items), nervousness (items items),and motor tension (two items). It is strange, however, to report a factor that has onlytwo-item loadings as this is not recommended in factor analysis (Costello and Osborne2005). However, a further analysis by Morin et al. settled on four factors. Ethnicity wasnot described in the study.

Very little has been done with regard to African (Steele and Edwards 2008) andAfrican-American (Chapman and Stegger 2008) cultures.

Chapman et al. (2009) in a study involving African-Americans and European–American young adults have proposed a two-factor solution as the four-factor andsix-factor solutions do not explain much.

The only known study that has used Africans who speak Xhosa (Steele and Edwards2008) identified four factors, but the factors were not named as some of the items werereported to have overlapped in various factors. Prior to this, Pillay et al. (2001) studyhad indicated that about 17.8 % of undergraduate students in a South African universitythat is predominantly Black and tested on the BAI scored in the severe range. Thus,there is very little reported on utility of the BAI in so far as Black Africans areconcerned.

This study therefore set out to determine the (1) utility of BAI among undergraduatestudents in Ghana, (2) differences between males and females reporting of anxiety, and

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(3) factor structure of the inventory among this population. To my knowledge, theinventory has not been standardized in Ghana.

Method

Participants The study consisted of 133 out of 178 undergraduate psychology studentswho volunteered to take part in the research. They were made up of 86 males and 47females aged between 21 and 34 years old with a mean age of 23.83 years (SD=3.21).All the participants were half way through their undergraduate studies (third yearstudents). English is the official language and medium of instruction for theparticipants, and, therefore, there was no need to translate the questionnaire. The studywas conducted at the beginning of the second semester of the academic year.

Instrument and Procedure The BAI which is made up of 21 questions and rated on afour-point Likert scale was administered. The scale ranges from 0 (not at all) to 3(severely) and the total scores can range from 0 to 63, with higher scores correspondingto higher levels of anxiety. Examples of some of the items are “nervous,” “Sweating notdue to heat,” and “feelings of choking.” The participants were administered with theBAI within class time taking just about 20 min to complete.

Data Analysis

SPSS version 16 was used for the analysis of data. Internal consistency (reliability) wasperformed to determine utility of the inventory. Exploratory factor analysis usingprincipal axis factoring with orthogonal (varimax) as well as oblique (promax) rotationswas employed to determine factor structure.

Results

Internal Consistency The Cronbach coefficient alpha for the BAI in this study was .93and indicates a high degree of internal consistency which is comparable to othersreported in the literature.

Table 1 reports the means, median, and standard deviations for gender and totalscore for the participants.

The mean full scale score was found to be very high with the males scoring slightlyhigher than the females. However, there was no significant difference between malesand females when an independent t test was performed (t (131)=.05, p>.05, two-tailed).

Table 1 Mean and median scoresfor the Beck Anxiety Inventory forthe participants according to gender

Gender Mean SD Median N

Male 17.69 12.66 15.00 86

Female 17.57 12.96 15.00 47

Total 17.65 12.72 15.00 133

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Item-Total Correlations

The means, standard deviations, and corrected item-total correlations of the BAI arepresented on Table 2.

The total item means was .84 ranging from .17 to 1.27, suggesting a mild tomoderate anxiety. Items rated high included feeling hot, unable to relax, fear of theworst happening, heart pounding or racing, nervous, and sweating not due to heat. Theitem-total correlations (r(tot)) ranged from .38 to .75 indicating a coherent scale.Nunnally and Bernstein (1994) recommend an acceptable item-total correlation of .30.

Factor Analysis of the BAI

To determine the factor structure for the BAI in this study, principal axis factoring withorthogonal (varimax) and oblique (promax) rotations was performed for comparison.First, the Kaiser-Meyer-Olkin sampling adequacy was performed and a score of .90was obtained indicating that the sample adequacy was marvelous. The Bartlett’s Test ofSphericity was significant (X2=1424.99, df=210, p<.000) and thus satisfying theconditions for proceeding with factor analysis.

Table 3 describes the initial factor extractions. In order to remove clutter, loadings ofless than .4 were suppressed (Stevens 1996: p. 372) and not indicated on the table. Four

Table 2 Means, standarddeviations, and corrected item-totalcorrelations for the BAI items

r(tot)=corrected item totalcorrelation

Items Mean S. D. r(tot)

1. Numbness or tingling .64 .86 .50

2. Feeling hot 1.26 .90 .39

3. Wobbliness in legs .70 .95 .55

4. Unable to relax 1.22 1.04 .67

5. Fear of the worst happening 1.09 1.09 .59

6. Dizzy or lightheaded .86 .95 .53

7. Heart pounding or racing 1.23 1.04 .68

8. Unsteady .83 .88 .71

9. Terrified .94 1.04 .75

10. Nervous 1.27 1.02 .70

11. Feelings of choking .51 .87 .56

12. Hands trembling .82 .95 .63

13. Shaky .85 .96 .74

14. Fear of losing control .72 .97 .73

15. Difficulty breathing .56 .92 .69

16. Fear of dying .56 .97 .54

17. Scared .99 1.02 .67

18. Indigestion or discomfort .99 1.01 .49

19. Faint .17 .58 .38

20. Face flushed .41 .68 .42

21. Sweating not due to heat 1.02 1.02 .52

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factors were extracted with eigenvalues more than 1.0. The scree plot also confirmedfour factors. Both varimax and promax rotations were compared. Table 3 shows thecomparisons of both varimax and promax and the items loading onto each factor; alsothe communalities (h2) of the measured variables are shown on the table.

The percent variances for the factors were 41.75, 6.88, 6.33, and 5.29, respectively,with a cumulative total percent variance of 60.25.

Loading unto factor 1 were ten items for varimax and seven for promax. Thecommon items between the two rotations on this factor related to wobbliness in legs,unable to relax, dizzy/lightheaded, unsteady, feeling hot, fear of the worst happening,and numbness or tingling; loadings for factor 2 were seven items for varimax and fiveitems for promax; factor 3 had six items for varimax and five items for promax, andfactor 4 had four items for varimax and two for promax.

Both the varimax and promax rotations showed a number of cross loading of itemsmaking it difficult to interpret. Secondly, factor 4 had only two loadings, i.e., “handstrembling” and “shaky” (both of which are somatic in nature) in promax which is not

Table 3 Comparison of factor loadings using varimax and promax

Items Orthogonal (varimax) factors Oblique (promax) factors

1 2 3 4 1 2 3 4 h2

1. Numbness or tingling .55 .69 .37

2. Feeling hot .44 .56 .24

3. Wobbliness in legs .46 .47 .37

4. Unable to relax .49 .52 .44 .42 .56

5. Fear of the worst happening .52 .44

6. Dizzy or lightheaded .53 .62 .65 .46

7. Heart pounding or racing .64 .61 .62

8. Unsteady .58 .59 .58

9. Terrified .44 .56 .47 .66

10. Nervous .42 .57 .51 .60

11. Feelings of choking .41 .46

12. Hands trembling .71 .78 .69

13. Shaky .45 .64 .66 .77

14. Fear of losing control .63 .58 .67

15. Difficulty breathing .43 .52 .44 .42 .66

16. Fear of dying .76 .86 .65

17. Scared .45 .52

18. Indigestion or discomfort .30

19. Faint .49 .58 .37

20. Face flushed .41 .45 .27

21. Sweating not due to heat .66 .75 .51

Eigenvalues 8.75 1.44 1.33 1.11

h2 =communality, loadings<.4 suppressed

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recommended (Costello and Osborne 2005). It may well be that those two items areconceptually inseparable. The decision then was to suspect three factors and tosuppress loadings less than .4 in order to remove more clutter. The results arereported in Table 4.

A three factor solution was revealed. In varimax, a number of items cross-loaded onall the factors, and they include items 4 (“unable to relax”), 8 (“unsteady”), 10(“nervous”), 13 (“shaky”), 14 (“fear of losing control”), 15 (“difficulty breathing”),and 17 (“scared”). In promax rotation, however, only one item (item 19) cross-loadedbut was more salient on factor 3. Promax rotation was therefore adopted as it was lesscluttered. Items loading onto factor 1 in promax were ten and the factor interpreted assomatic with a Cronbach coefficient alpha of .87 factor 2 was composed of five itemsand was labeled as autonomic with a Cronbach coefficient alpha of .86, and factor 3had four items reflecting fear/panic with a Cronbach coefficient alpha of .72. The factorscore correlations ranged from .51 to .65. Factor 1 correlated with factors 2 and 3(r=.65 and .64, respectively), while factor 2 correlated with factor 3 (r=.51). Thus thecorrelations between the factors were moderate.

Table 4 Comparison of factor loadings using varimax and promax

Items Orthogonal (varimax) factors Oblique (promax) factors

1 2 3 1 2 3 h2

1. Numbness or tingling .50 .63 .33

2. Feeling hot .44 .54 .23

3. Wobbliness in legs .47 .48 .37

4. Unable to relax .41 .60 .57 .55

5. Fear of the worst happening .47 .43 .39

6. Dizzy or lightheaded .30

7. Heart pounding or racing .69 .72 .62

8. Unsteady .52 .44 .44 .55

9. Terrified .61 .57 .65

10. Nervous .41 .64 .61 .61

11. Feelings of choking .54 .41 .57 .46

12. Hands trembling .59 .63 .49

13. Shaky .62 .46 .60 .64

14. Fear of losing control .42 .63 .57 .67

15. Difficulty breathing .62 .51 .63 .66

16. Fear of dying .75 .83 .64

17. Scared .43 .46 .49

18. Indigestion or discomfort .46 .49 .30

19. Faint .52 -.42 .62 .39

20. Face flushed .41 .42 .25

21. Sweating not due to heat .61 .70 .44

Loadings<.4 suppressed; h2 =communality

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Discussion

The study, to my knowledge, is the first to examine the reliability and factor structuresfor the BAI among Ghanaian undergraduate students.

The Cronbach coefficient alpha was high and consistent with previous alphasreported in the literature (Steele and Edwards 2008). As suggested by Nunnally(1978) and Terre-Blanche and Durrheim (1999), alpha values of between .70 and .75indicate that the scale has a high internal consistency and is useful for research and auseful clinical tool as well for this group of people as alpha was very high. Thus, forthese participants in this study, the scale is a useful tool for anxiety screening.

In previous studies, the reported mean full scale score for the BAI for non-clinicalsamples has ranged between 8.83 (SD=6.92) and 18.14 (SD=12.88) (Beck et al. 1988;Hewitt and Norton 1993), respectively. However, Novy et al. (2001) reported a mean of23 (SD=14.8) among a non-clinical sample of Hispanics. Pillay et al. (2001) had alsoreported that 17.8 % of their undergraduate sample also scored in the severe range.

The results from this study indicate a mean that is consistent with many reportedstudies. Although, this is not from a clinical population, the score seems to suggest thatat the time of the study, the participants were functioning within the moderate range ofanxiety as classified by Beck and Steer (1993) and about 21 % (20.8 %) of them werescoring in the severe range. There could be many reasons why the mean score washigh. These are students most of whom are residing outside the university campus asthe university does not offer accommodation to students who are not in the first year.Hence, they may be having financial pressures in the areas of feeding, accommodation,and transport on top of their busy academic schedule. An interesting aspect of the studyis that there was no significant difference between males and females on the inventorywhen an independent t test was performed. It may well be that the females wereunderreporting or the males were exaggerating. Previous studies have indicated thatfemales tend to score higher on the scale than males (Beck and Steer 1993; Hewitt andNorton 1993; Osman et al. 1993). In a nonclinical sample study, sex differences wereobserved with females showing more cognitive misinterpretations about the symptomsof anxiety (Armstrong and Khawaja 2002).

Most studies have reported two- or four-factor structures for the BAI. As indicatedpreviously, this study sought to determine the factor structure of the BAI among thisparticular population, and a three-factor structure was revealed. This raises a number ofissues regarding interpretation of items, concepts from cultural perspectives, as well asdifferences between clinical and nonclinical populations. For example, some of the itemsare named differently by different authors. Feelings of choking and indigestion are seenas somatic by Kabacoff et al. (1997), but Beck et al. (1988) considered them assubjective. The same items were seen as autonomic and panic, respectively, by Osmanet al. (1993). Morin et al. (1999) described feelings of choking as panic. For items dealingwith inability to relax, fear of the worst happening, terrified, nervous, and fear of losingcontrol, Osman referred to them as neurophysiological symptoms, whereas Beck et al.(1988), Kabacoff et al. (1997), and Chapman et al. (2009) referred to them as subjective.Again, Osman et al. (1993) referred to “face flushed” and “sweating not due to heat” aspanic symptoms but they came under somatic symptoms in the views of Beck et al.,Kabacoff et al., and Chapman et al. Another issue is the fact that different authors havereported different loading limits and that may account for some of the differences.

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In summary, three main issues have arisen from this study as follows: (1) the meanfull scale score for this group is high although not inconsistent with other studies, (2)the reliability coefficient is comparable with most studies and therefore the BAI couldbe potentially useful in the Ghanaian context for anxiety screening, and (3) three factorswere revealed instead of two or four reported by many other researchers.

Some of the limitations to this study include using undergraduate students whopossibly were experiencing a lot of stress with respect to finance, accommodationissues, and academic work. Secondly, it could well be that some of the responses wereexaggerated, and thirdly only students from one department were involved. A furtherstudy with a larger sample may be needed to ascertain the appropriateness of theresponses and its clinical utility.

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