Development and validation of a questionnaire to assess environmental and lifestyle factors influencing infectious disease outcomes: application to SARS-CoV-2-infected individuals in Cuba

BACKGROUND AND OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic highlighted the influence of behavioral and environmental factors on the risk of infection, as well as on disease progression and severity. Therefore, it is critical to improve public health knowledge regarding the factors influencing disease outcomes. This study describes the development and validation of the "Cuban population environmental and lifestyle factors Questionnaire" (CELF-Q), a tool designed to evaluate the impact of environmental and lifestyle factors on COVID-19 outcomes in the Cuban population.

STUDY DESIGN AND SETTING: Based on an existing lifestyle questionnaire developed for the Latin American population, a thorough process of modification, cross-cultural adaptation, and iterative desk review was conducted to generate the CELF-Q. Pre-test analysis was performed to assess face and content validity. To evaluate content validity, a panel of 15 experts was selected. Test-retest reliability was assessed in 60 participants, while internal consistency was evaluated by administering the questionnaire to 309 individuals with SARS-CoV-2 infection. Confirmatory factor analysis (CFA) was performed to assess the fit of the CELF-Q's factor structure.

RESULTS: The content validity of the questionnaire was deemed "acceptable" across several dimensions, based on the results of the content validity ratio (CVR), content validity index (CVI), and Aiken's validity (V). Only a few items were identified for revision using these quantitative measures. Additionally, the experts supplemented the evaluations with qualitative comments for the modification of the questions. The test-retest reliability analysis showed an overall mean kappa coefficient of 0.89 [standard deviation (SD): 0.21] and a mean overall correlation coefficient of 0.99 (0.02), indicating high to almost perfect agreement. An internal consistency analysis showed that the majority of the dimensions had acceptable Cronbach's alpha values. In particular, the self-care behavior, socioeconomic restrictions, and diet and nutritional habits dimensions achieved respectable Cronbach's alpha values (between 0.7 and 0.8).

CONCLUSION: The generated CELF-Q is a comprehensive, valid, and reliable tool for obtaining information on environmental/lifestyle factors associated with SARS-CoV-2 infection, as well as the development and severity of COVID-19, in the Cuban population.