ABSTRACT

Objective.

To design and validate an instrument to assess the perceived risk of contracting COVID-19 in the Colombian population.

Materials and methods.

Cross-sectional observational study of psychometric type with a sample of 2350 people between 16 and 65 years of age. The dimensions and items were proposed based the review of previous studies on the evaluation of risk perception of disease and disasters, by integrating the guidelines issued by the World Health Organization regarding self-protection measures and biosecurity protocols to avoid COVID-19 transmission. The validation process was carried out in two stages; the first stage included a review by expert judges who evaluated the clarity, sufficiency, and relevance of each item in relation to the variable and its dimension; in the second stage we carried out a confirmatory factor analysis and estimated internal consistency with the Cronbach’s Alpha (α) and McDonald’s omega (ω) indexes.

Results.

The designed instrument had adequate psychometric properties to evaluate the risk perception of contracting COVID-19 (α=0.924), with four dimensions: cognitive vulnerability (α=0.873), emotional vulnerability (α=0.882), severity (α=0.893) and risk-protective behaviors (α=0.941).

Conclusions.

These findings show that the instrument to evaluate the risk perception of contracting COVID-19 (PCR-CV19) is a valid and reliable tool to assess contagion risk perception and can be adapted to different population groups and contexts.

Keywords:
COVID-19; Perception; behaviors; risk of contagion; validity; reliability

INTRODUCTION

The COVID-19 pandemic, caused by the SARS COV-2 coronavirus, is described as a global public health emergency ¹1. Ramírez-Ortiz J, Castro-Quintero D, Lerma-Córdoba C, Yela-Ceballos F, Escobar-Córdoba F. Mental health consequences of the COVID-19 pandemic associated with social isolation. Colomb J Anesthesiol. 2020;48(4). doi: 10.5554/22562087.e930.
https://doi.org/10.5554/22562087.e930... with diverse psychosocial and mental health consequences ²2. Gallegos M, Zalaquett C, Luna Sánchez S, Mazo-Zea R, Ortiz-Torres B, Penagos-Corzo J, et al. Cómo afrontar la pandemia del Coronavirus (Covid-19) en las Américas: recomendaciones y líneas de acción sobre salud mental. Interam J Psychol. 2020;54(1): e1304. doi: 10.30849/ripijp.v54i1.1304
https://doi.org/10.30849/ripijp.v54i1.13... ^,33. Antiporta D, Bruni A. Emerging mental health challenges, strategies, and opportunities in the context of the COVID-19 pandemic: Perspectives from South American decision-makers. Rev Panam Salud Publica. 2020; 44:154. doi: 10.26633/RPSP.2020.154.
https://doi.org/10.26633/RPSP.2020.154... . The quick spread in the population and its capacity to reach at-risk groups made it impossible for health services to respond properly ⁴4. Uruzua A, Villarroel P, Carrasco R. La Psicología en la prevención y manejo del COVID- 19 Aportes desde la evidencia inicial. Terapia Psicológica. 2020; 38(1) 103-118. Disponible en: http://dx.doi.org/10.4067/S0718-48082020000100103.
http://dx.doi.org/10.4067/S0718-48082020... . This is why the World Health Organization (WHO) indicated that the best way to stop and prevent COVID-19 is to be well informed about how the virus spreads in order to take protective measures ⁵5. Orte C, Sánchez-Prieto L, Domínguez D, Barrientos-Báez A. Evaluation of distress and risk perception associated with COVID-19 invulnerable groups. Int J Environ Res Public Health. 2020;17(24):9207. doi: 10.3390/ijerph17249207.
https://doi.org/10.3390/ijerph17249207... .

Experiences in outbreak control of communicable diseases such as Middle East respiratory syndrome and swine flu showed that the strategies and the results obtained required, to a large extent, people’s risk perception ⁶6. Costa-Sánchez C, López-García X. Comunicación y crisis del coronavirus en España. Primeras lecciones. Inf Prof. 2020;29(3):1-14. doi: 10.3145/epi.2020.may.04.
https://doi.org/10.3145/epi.2020.may.04...

7. Samadipour E, Ghardashi F, Aghaei N. Evaluation of risk perception of COVID-19 disease: A community-based participatory study. Disaster Med Public Health Prep. 2020;1-8. doi: https://doi.org/10.1017/dmp.2020.311.
https://doi.org/https://doi.org/10.1017/... ^-88. Mejia C, Rodriguez-Alarcon J, Garay-Rios L, Enriquez-Anco M, Moreno A, Huaytan-Rojas K, et al. Percepción de miedo o exageración que transmiten los medios de comunicación en la población peruana durante la pandemia de la COVID-19. Rev Cubana Inv Bioméd. 2020; 39(2):e698. Disponible en: http://www.revibiomedica.sld.cu/index.php/ibi/article/view/698.
http://www.revibiomedica.sld.cu/index.ph... . In this sense, risk perception is a concept used in public health because of its association with preventive behavior in the face of events and diseases ⁹9. Saletti-Cuesta L, Tumas N, Berra S. Percepción de riesgo ante el coronavirus en la primera fase de la pandemia en Argentina. Hacia Promoc Salud 2021; 26 (1): 163-178 doi: https://doi.org/10.17151/hpsal.2021.26.1.13.
https://doi.org/https://doi.org/10.17151... , and is of great interest for its application during the COVID-19 pandemic ⁽⁷7. Samadipour E, Ghardashi F, Aghaei N. Evaluation of risk perception of COVID-19 disease: A community-based participatory study. Disaster Med Public Health Prep. 2020;1-8. doi: https://doi.org/10.1017/dmp.2020.311.
https://doi.org/https://doi.org/10.1017/... ^,1010. Robles-Sánchez J. La Psicología de Emergencias ante la COVID-19: Enfoque desde la Prevención, Detección y Gestión Operativa del Riesgo. Clin Salud. 2020;31(2):115-8. doi: https://doi.org/10.5093/clysa2020a17.
https://doi.org/https://doi.org/10.5093/... ^,1111. Sánchez-González M. Historia y futuro de las pandemias. Rev Med Clin Condes. 2021;32(1):7-13. doi: 10.1016/j.rmclc.2020.12.007.
https://doi.org/10.1016/j.rmclc.2020.12.... .

Risk perception can be understood as the knowledge of the effects, damages and degree of susceptibility and consequences ¹²12. Brewer N, Weinstein N, Cuite C, Herrington J. Percepciones del riesgo y su relación con el comportamiento del riesgo. Ann Behav Med. 2004;27(2):125-30. doi: 10.1207/s15324796abm2702_7.
https://doi.org/10.1207/s15324796abm2702... ; it refers to the individual’s feeling and understanding of risks in the outside world, a subjective judgment that people create ¹³13. García del Castillo J. Concepto de percepción de riesgo y su repercusión en las adicciones. Salud y drogas. [Internet]. 2012;12(2):133-151. Disponible en: https://www.redalyc.org/articulo.oa?id=83924965001.
https://www.redalyc.org/articulo.oa?id=8... . Regarding the assessment of risk perception, there are two models, the disease model ¹⁴14. Pérez-Fuentes M, Molero M, Oropesa N, Martos Á, Simón M, Herrera-Peco I, et al. Questionnaire on perception of threat from COVID-19. J Clin Med. 2020;9(4):1196. doi: 10.3390/jcm9041196.
https://doi.org/10.3390/jcm9041196... and the disaster model ⁷7. Samadipour E, Ghardashi F, Aghaei N. Evaluation of risk perception of COVID-19 disease: A community-based participatory study. Disaster Med Public Health Prep. 2020;1-8. doi: https://doi.org/10.1017/dmp.2020.311.
https://doi.org/https://doi.org/10.1017/... ^,1515. Shen Z, Zhong Z, Xie J, Ding S, Li S, Li C. Development and psychometric assessment of the public health emergency risk perception scale: Under the outbreak of COVID-19. Int J Nurs Sci. 2021;8(1):87-94. doi: 10.1016/j.ijnss.2020.12.012.
https://doi.org/10.1016/j.ijnss.2020.12.... . The disease perception model focuses on the representations or perceptions that the individual has about the experience with a disease, the origin, consequences, treatment, causes, duration and cure; it is conditioned by experience, social and cultural context that influence preventive behavior ¹⁴14. Pérez-Fuentes M, Molero M, Oropesa N, Martos Á, Simón M, Herrera-Peco I, et al. Questionnaire on perception of threat from COVID-19. J Clin Med. 2020;9(4):1196. doi: 10.3390/jcm9041196.
https://doi.org/10.3390/jcm9041196... . The disaster model follows three theories, psychometric, cultural and social reinforcement. According to the psychometric model, the key factors in people’s risk perception are fear and risk of the unknown ¹¹11. Sánchez-González M. Historia y futuro de las pandemias. Rev Med Clin Condes. 2021;32(1):7-13. doi: 10.1016/j.rmclc.2020.12.007.
https://doi.org/10.1016/j.rmclc.2020.12.... . The cultural theory focuses on social organizations and activities, and the social reinforcement framework theory communicates psychological, social, institutional, and cultural risk ⁷7. Samadipour E, Ghardashi F, Aghaei N. Evaluation of risk perception of COVID-19 disease: A community-based participatory study. Disaster Med Public Health Prep. 2020;1-8. doi: https://doi.org/10.1017/dmp.2020.311.
https://doi.org/https://doi.org/10.1017/... .

Worldwide, there are studies that evaluate the risk perception of COVID-19 infection based on the disease or disaster model. In Asia, particularly in China, risk perception was evaluated based on the disaster model, with the psychometric paradigm, and the risk characteristics were described with the dimensions: unknown and fearful ¹⁵15. Shen Z, Zhong Z, Xie J, Ding S, Li S, Li C. Development and psychometric assessment of the public health emergency risk perception scale: Under the outbreak of COVID-19. Int J Nurs Sci. 2021;8(1):87-94. doi: 10.1016/j.ijnss.2020.12.012.
https://doi.org/10.1016/j.ijnss.2020.12.... . In Iran, a study was carried out with the dimensions: cognitive, political, social and cultural ⁷7. Samadipour E, Ghardashi F, Aghaei N. Evaluation of risk perception of COVID-19 disease: A community-based participatory study. Disaster Med Public Health Prep. 2020;1-8. doi: https://doi.org/10.1017/dmp.2020.311.
https://doi.org/https://doi.org/10.1017/... . In some European countries, such as Spain, researchers have validated the illness perception questionnaire (IPQ) for COVID-19 (perception of the threat of illness); other studies have evaluated health protection factors and psychological measures ⁵5. Orte C, Sánchez-Prieto L, Domínguez D, Barrientos-Báez A. Evaluation of distress and risk perception associated with COVID-19 invulnerable groups. Int J Environ Res Public Health. 2020;17(24):9207. doi: 10.3390/ijerph17249207.
https://doi.org/10.3390/ijerph17249207... , information content, false news and ideologies based on the Morton and Duck scale ¹⁶16. Mora-Rodríguez A, Melero-López I. News consumption and risk perception of Covid-19 in Spain. Comunicar. 2021;29(66):71-81. doi: 10.3916/C66-2021-06.
https://doi.org/10.3916/C66-2021-06... as well as the perceived threat ¹⁷17. Molero M, Herrera-Peco I, Pérez-Fuentes M, Gázquez J. Análisis de la amenaza percibida por la COVID-19 en población española. Aten Primaria. 2020; 52(7): 515-516. doi: 10.1016/j.aprim.2020.05.001.
https://doi.org/10.1016/j.aprim.2020.05.... . In Italy, researchers have evaluated the perceived risk and the severity of anxiety (concern about being infected and concern about infecting their family members) ¹⁸18. Germani A, Buratta L, Delvecchio E, Gizzi G, Mazzeschi C. Anxiety severity, perceived risk of COVID-19 and individual functioning in emerging adults facing the pandemic. Front Psychol. 2020;11: 567505. doi: 10.3389/fpsyg.2020.567505.
https://doi.org/10.3389/fpsyg.2020.56750... .

In Latin America, a Mexican descriptive study used the CPR-COVID19, a questionnaire on preventive and risk behavior, which evaluates knowledge of the disease, health history, risk behavior and preventive behavior during quarantine ¹⁹19. Camacho-Valadez D. Comportamiento preventivo y de riesgo en México durante la pandemia del COVID-19: Estudio descriptivo a nivel nacional. Revista de salud pública. [Internet].2020. Disponible en: https://www.researchgate.net/publication/342212461_Comportamiento_preventivo_y_de_riesgo_en_Mexico_durante_la_pandemia_del_COVID-19_Estudio_descriptivo_a_nivel_nacional.
https://www.researchgate.net/publication... . In addition, another Mexican study on the perception of risk and media consumption of the coronavirus at the beginning of the pandemic was based on the Morton and Duck scale ²⁰20. Muñiz C, Corduneanu V. Percepción de riesgo y consumo mediático durante el inicio de la pandemia de COVID-19 en México. [Internet]. 2020; 44-47. Disponible en: https://www.researchgate.net/publication/341273339_Percepcion_de_riesgo_y_consumo_mediatico_durante_el_inicio_de_la_pandemia_de_COVID-19_en_Mexico.
https://www.researchgate.net/publication... . Meanwhile, a Colombian study aimed to determine the levels of risk perception regarding COVID-19 in university students, with three factors: susceptibility to illness, perceived severity in case of illness and protective behaviors ²¹21. Rosero A, Carvajal J, Bolaños E. Percepción del riesgo frente al COVID-19 en adolescentes escolarizados colombianos. Universidad de Nariño, San Juan de Pasto, Colombia. Revista Boletín Redipe. 2021;10 (2): 201-217.. Thus, there is no consensus on which dimensions of risk perception should be assessed.

The aim of this study was to design and validate an instrument to assess the perceived risk of COVID-19 infection in the Colombian population.

MATERIALS AND METHODS

Design and study population

This is an observational, cross-sectional psychometric study. The participants were selected by means of a stratified, proportional and random sampling, seeking representativeness of the departments of Colombia (Casanare, Cauca, Cesar, Córdoba, Cundinamarca, Huila, Boyacá, Guajira, Antioquia, Meta, Nariño, Norte de Santander, Putumayo, Quindío, Risaralda, Santander, Sucre, Arauca, Tolima, Valle del Cauca, Atlántico and Bolívar); with a sample size of 2350 persons between 16 and 65 years of age, which corresponds to the Namakforoosh formula (2000), considering a confidence level of 95%, estimation error of 5% and is valid for the three types of test, i.e. reliability, factor analysis and metric proposal.

Instrument and procedure

We proposed the dimensions and items included in the questionnaire of the perceived risk of COVID-19 infection (PCR- CV19) based on a theoretical review of this construct and the disease and disaster assessment models, which include WHO guidelines on how to assess the knowledge, perceptions and behavior of citizens related to COVID-19 with regard to the adoption of preventive measures to avoid infection, risk perceptions regarding the disease, probability-susceptibility and severity²²22. Organización Mundial de la Salud. Consideraciones relativas a las medidas de salud pública y sociales en el lugar de trabajo en el contexto de la COVID-19. Anexo a las Consideraciones relativas a los ajustes de las medidas de salud pública y sociales en el contexto de la COVID-19. [Internet]. 2020. [Citado el 10 de mayo de 2020]. Disponible en: https://apps.who.int/iris/handle/10665/332084.
https://apps.who.int/iris/handle/10665/3... ^-2323. Organización Mundial de la Salud. Brote de enfermedad por Coronavirus (COVID-19). [Internet]. 2021 [Citado el 14 de agosto del 2021]. Disponible en: https://www.who.int/es/emergencies/diseases/novel-coronavirus-2019/advice-for-public.
https://www.who.int/es/emergencies/disea... .

The validation process took place in two moments. Before the application of the PCR-CV19 there was a first moment of independent review by five judges, experts in medical and health psychology, who evaluated on a scale of 1 to 5 points the clarity, sufficiency and relevance of each of the 40 items of the instrument with regard to the total variable (min=120 max=600 x̄=480) and the vulnerability dimensions (min=40 max=200 x̄=164), risk-protective behaviors (min=40 max=200 x̄=158) and severity (min=40 max=200 x̄=160). Initially an overall approval of 80% was obtained and after adjustments, 100% (total instrument=600 and per dimension=200). In a second moment, factor analysis was carried out to determine whether the data yielded evidence in favor of the dimensions. The survey was distributed as a Google form during the months of October 2020 to March 2021.

Variables and operationalization

The perception index of the questionnaire is quantitative, with a compact interval range [0,1 ], which allows interpretation in percentages, and facilitates understanding and modeling. The items are measured using an ordinal scale and the levels are identified as “Very Low”, “Low”, “Equal”, “High” and “Very High”; for the purposes of calibration and definition of the index, they were labeled with numbers from 1 to 5, maintaining the same sequence.

Data analysis

To evaluate the construct validity of the instrument we used the Gamma index (Γ), defined by González et al. ²⁵25. González J, Carvajal C, Viveros F. Coeficientes edumétricos para la validez y dificultad de una prueba: Propuesta. Estudios pedagógicos (Valdivia) [Internet]. 2016. 42(3) Disponible en: https://scielo.conicyt.cl/scielo.php?script=sci_abstract&pid=S0718-07052016000400025&lng=es&nrm=iso.
https://scielo.conicyt.cl/scielo.php?scr... , which is determined according to the ratios between the self-values or values of the variance-covariance matrix and the concept of one-dimensionality, as well as the factor analysis, contrasting the exploratory with the confirmatory and estimated on the total sample, considering the percentage of variance based on the Bartlett’s factor scores method and its significance. The application of the factor analysis is supported by the evidence provided by the sample adequacy tests (KMO); the rotation was Oblimin in all cases.

As for the reliability of the instrument, we used Cronbach’s alpha and McDonald’s Omega statistics ²⁶26. Hernandez R, Fernández C, Baptista M. Metodología de la Investigación México. McGrau-Hill; 2014. as estimators of internal consistency, the former being contrasted with the Alpha Game coefficient to determine whether there was negative covariance ²⁷27. González JA, Aspeé J. Propuesta de estimador de la fiabilidad mediante alpha game. Revista Iberoamericana de Psicología. 2021. Disponible en: https://reviberopsicologia.ibero.edu.co/article/view/rip.14101/1673.
https://reviberopsicologia.ibero.edu.co/... . The instrument is considered reliable if it reaches a coefficient equal to or greater than 0.7.

On the other hand, to define the PCR-CV19 index, we carried out a descriptive analysis in coherence with the metric status of each of the dimensions. Subsequently, we performed inferential tests on possible values for the centrality parameter of the index, using the p-value statistic and a significance level of 5% as decision criteria. Finally, a distributional model for the index was proposed, using the AIC and BIC criteria for model selection. The statistical analyses were performed with the R 3.6.1 software (R Development Core Team, 2019) and Jamovi 1.2.27.

Proposed metric for the risk perception index

The definition of the index is established by standardizing the total score of the instrument. The arithmetic means or averages were calculated for each of the factors, because they do not necessarily have the same number of items, and then we calculated the mean of these. The score obtained was divided by 5, according to the number of response alternatives that characterized each item. Formally, the PCR-CV19 index can be represented by:

In which PP Di represents the average score of the i-th dimension of the instrument, that is, if the second dimension is the one being studied, then 𝑃𝑃 𝐷2 represents the average score of the second dimension.

According to the definition, the index had a compact interval, which was I_PCR ∈ [0;1 ]; this allowed interpretations to be made in percentage terms and also to be categorized. The analysis procedure was initially carried out by determining, from the observed sample, the PCR-CV19 index, the calculation of the lambda and kappa parameters, the determination of the Expectation and Variance as a function of the estimates and, according to the graphical representation of the best model as a function of the estimates, the determination of probabilities and comparisons in form and the elaboration of conclusions.

Ethical considerations

The Google form included the informed consent document that allowed the confidentiality and anonymity of the participants to be preserved. This study was evaluated and endorsed by the Ethics Committee of the Universidad Nacional Abierta y a Distancia UNAD.

RESULTS

The main component of the instrument we designed is the perception of risk (susceptibility-vulnerability), defined as the probability of contracting a given disease in two dimensions, personal (probability of being affected by a hazard-threat) and comparative (in comparison to other people of the same sex and age) ²⁴24. Jones C, Jensen J, Scheer C, Brown N, Christy K, Weaver J. El modelo de creencias en salud como marco explicativo en la investigación en comunicación: exploración de la mediación paralela, en serie y moderada. Biblioteca Nacional de Medicina. 2015;30(6):76-566., as shown in Table 1.

In this sense, we obtained the following dimensions of the PCR- CV19: cognitive vulnerability, emotional vulnerability, risk-protection behaviors and severity. Vulnerability was defined as the probability of contracting a given disease in two dimensions, personal and comparative, and was based on the disease model. The risk-protection behaviors dimension was associated with the disaster model due to the social, cultural and political perception of risk in following self-protection measures and biosafety protocols. The severity dimension was based on the disease model due to the conception of health damage (complications) and on the disaster model due to the socioeconomic impact and deaths caused by COVID-19.

Psychometric properties of the PCR- CV19 questionnaire. Reliability and validity

The validity estimate, in the Gamma statistic, was 0.798, which means that the data support evidence in favor of the one-dimensionality of the instrument. The construct validity by factor analysis (KMO statistic (≥ 0.8)) shows a percentage of explained variance based on Bartlett’s factor scores method above 50%, being significant at p<0.01 (Table 2). In the confirmatory factor analysis, the dimensions proposed from the theoretical models of risk perception assessment were maintained, as shown in Tables 3, 4 and 5; therefore, the PCR-CV19 questionnaire was made up of four factors (p<0.001): cognitive vulnerability (factor 1), emotional vulnerability (factor 2), risk-protective behaviors (factor 3), and severity (factor 4).

The reliability estimate of the total instrument is high, Cronbach’s Alpha (0.924), McDonald’s Omega (0.929), and in a confirmatory manner the Alpha Game coefficient (0.924), establishing that there are no negative covariances (Table 5); the estimates of the reliability of the dimensions are also high, as can be seen in Table 2. Therefore, the PCR-CV19 is considered a valid and reliable instrument, in terms of internal consistency and for the three estimates above 0.7 of reference.

PCR-CV19 index and distributional adjustment

The process of model adjustment of the index is rigorous for selecting the best model, which summarizes the data dynamics more accurately by using criteria such as BIC, AIC and logL, among others. The Weibull distribution was used as a model for the PCR-CV19 index, because it has the lowest scores for BIC (-627.85) and AIC (-635.56), and the highest for LogL (319.78), thus justifying its use (KS=0.05). In this case the estimated values for the parameters are lambda (0.815) and kappa (9.19). Finally, based on the values of the PCR-CV19 index, were propose five categories, these being very low (0;0.2), low (0.2;0.4), moderate (0.4;0.6), high (0.6;0.8) and very high (0.8;1), established in a classical manner, that is, generating partitions of equal amplitude.

In the case of the calibration sample, a “High” category is obtained for the PCR-CV19 index with an orientation toward the Risk-Protection Behavior dimension. Likewise, it is possible to estimate transition probabilities, i.e., to move from one category to another; for example, if two groups of students are being compared, conditional probabilities can be established, whereby, in the case of being in the “Low” category, what is the probability of moving to the “Moderate” category, which can then be used as a prioritization and/or comparison tool.

In line with the above, in terms of centrality and based on the mean, it can be established that the PCR-CV19 index identifies a sample in the “High” category, and we obtained 13% variability using the variation coefficient, characterizing a homogeneous sample. Regarding the analysis of extreme values, we observed that the PCR-CV19 index has a minimum value of 0.32, being identified as “Low”, and the maximum 1.0 as “Very High”. On the other hand, we observed negative asymmetry, evidencing a tendency to large values, similar for the case of kurtosis where we observed a leptokurtic behavior.

Based on the summary, we can state that the predominant orientation of the sample was found to be with the factor “Risk-Protection Behaviors”. As for the conditional probabilities, given that the observed sample is in the “High” category, the probability that it will change to the “Very High” status is 0.0234; for example, if the observed sample were categorized as “Low”, the probability that it would move up to the “Moderate” category would be 0.0278.

Thus, we defined the orientation of the PCR-CV19 index, since it can be supported mainly by one of the factors; this means that two sample units can have the same score in the PCR-CV19 index, but be supported by different factors. For example, a PCR-CV19 index based on cognitive vulnerability is not the same as one based on severity, therefore, the report that allows this proposed metric structure is two-dimensional; on the one hand there is the index report, which allows categorization and, on the other hand, the main support for obtaining that category is evidenced. Formally, the orientation of the PCR index is given by the factor with the maximum mean or average.

DISCUSSION

This study has designed the PCR-CV19 questionnaire and the results show it to be a valid and reliable instrument for assessing the perception of risk of COVID-19 infection through 40 items distributed in four dimensions: cognitive vulnerability, emotional vulnerability, risk-protective behaviors and severity. Therefore, it is a questionnaire that could be adapted to other realities or countries, since these dimensions make it possible to identify, understand and analyze the conditions of risk, as well as the process that leads to its occurrence ¹⁰10. Robles-Sánchez J. La Psicología de Emergencias ante la COVID-19: Enfoque desde la Prevención, Detección y Gestión Operativa del Riesgo. Clin Salud. 2020;31(2):115-8. doi: https://doi.org/10.5093/clysa2020a17.
https://doi.org/https://doi.org/10.5093/... . All these dimensions interact with each other contributing to the adoption of preventive measures ²⁸28. Restrepo J. El concepto de riesgo: avances hacia un modelo de percepción de riesgo en salud. Psicoespacios. 2016;10(16): 174. doi: 10.25057/21452776.718.
https://doi.org/10.25057/21452776.718... , as well as in the mental health of the general population ²2. Gallegos M, Zalaquett C, Luna Sánchez S, Mazo-Zea R, Ortiz-Torres B, Penagos-Corzo J, et al. Cómo afrontar la pandemia del Coronavirus (Covid-19) en las Américas: recomendaciones y líneas de acción sobre salud mental. Interam J Psychol. 2020;54(1): e1304. doi: 10.30849/ripijp.v54i1.1304
https://doi.org/10.30849/ripijp.v54i1.13... ^,1515. Shen Z, Zhong Z, Xie J, Ding S, Li S, Li C. Development and psychometric assessment of the public health emergency risk perception scale: Under the outbreak of COVID-19. Int J Nurs Sci. 2021;8(1):87-94. doi: 10.1016/j.ijnss.2020.12.012.
https://doi.org/10.1016/j.ijnss.2020.12.... ^,2929. Xiang, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, et al. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry. 2020;7(3):228-9. doi: 10.1016/S2215-0366(20)30046-8.
https://doi.org/10.1016/S2215-0366(20)30... .

The PCR-CV19 questionnaire (Annex 1) assesses dimensions of risk perception in accordance with studies based on the disease model ⁵5. Orte C, Sánchez-Prieto L, Domínguez D, Barrientos-Báez A. Evaluation of distress and risk perception associated with COVID-19 invulnerable groups. Int J Environ Res Public Health. 2020;17(24):9207. doi: 10.3390/ijerph17249207.
https://doi.org/10.3390/ijerph17249207... ^,1919. Camacho-Valadez D. Comportamiento preventivo y de riesgo en México durante la pandemia del COVID-19: Estudio descriptivo a nivel nacional. Revista de salud pública. [Internet].2020. Disponible en: https://www.researchgate.net/publication/342212461_Comportamiento_preventivo_y_de_riesgo_en_Mexico_durante_la_pandemia_del_COVID-19_Estudio_descriptivo_a_nivel_nacional.
https://www.researchgate.net/publication... ^,2121. Rosero A, Carvajal J, Bolaños E. Percepción del riesgo frente al COVID-19 en adolescentes escolarizados colombianos. Universidad de Nariño, San Juan de Pasto, Colombia. Revista Boletín Redipe. 2021;10 (2): 201-217. and the disaster model ⁽¹⁶16. Mora-Rodríguez A, Melero-López I. News consumption and risk perception of Covid-19 in Spain. Comunicar. 2021;29(66):71-81. doi: 10.3916/C66-2021-06.
https://doi.org/10.3916/C66-2021-06... ^-1717. Molero M, Herrera-Peco I, Pérez-Fuentes M, Gázquez J. Análisis de la amenaza percibida por la COVID-19 en población española. Aten Primaria. 2020; 52(7): 515-516. doi: 10.1016/j.aprim.2020.05.001.
https://doi.org/10.1016/j.aprim.2020.05.... . However, in comparison with these studies, the PCR-CV19 is an instrument that, in addition to integrating the risk perception assessment models, presents greater sensitivity and can be adapted to different population groups and contexts (e.g., educational, occupational, health), as well as presenting its scoring and interpretation rules.

Regarding the PCR-CV19 dimensions, this instrument distinguishes between cognitive vulnerability and emotional vulnerability in contrast with others ⁵5. Orte C, Sánchez-Prieto L, Domínguez D, Barrientos-Báez A. Evaluation of distress and risk perception associated with COVID-19 invulnerable groups. Int J Environ Res Public Health. 2020;17(24):9207. doi: 10.3390/ijerph17249207.
https://doi.org/10.3390/ijerph17249207... ^,1919. Camacho-Valadez D. Comportamiento preventivo y de riesgo en México durante la pandemia del COVID-19: Estudio descriptivo a nivel nacional. Revista de salud pública. [Internet].2020. Disponible en: https://www.researchgate.net/publication/342212461_Comportamiento_preventivo_y_de_riesgo_en_Mexico_durante_la_pandemia_del_COVID-19_Estudio_descriptivo_a_nivel_nacional.
https://www.researchgate.net/publication... ^,2121. Rosero A, Carvajal J, Bolaños E. Percepción del riesgo frente al COVID-19 en adolescentes escolarizados colombianos. Universidad de Nariño, San Juan de Pasto, Colombia. Revista Boletín Redipe. 2021;10 (2): 201-217.^,1616. Mora-Rodríguez A, Melero-López I. News consumption and risk perception of Covid-19 in Spain. Comunicar. 2021;29(66):71-81. doi: 10.3916/C66-2021-06.
https://doi.org/10.3916/C66-2021-06... ^,1717. Molero M, Herrera-Peco I, Pérez-Fuentes M, Gázquez J. Análisis de la amenaza percibida por la COVID-19 en población española. Aten Primaria. 2020; 52(7): 515-516. doi: 10.1016/j.aprim.2020.05.001.
https://doi.org/10.1016/j.aprim.2020.05.... , in terms of the probability of being affected by COVID-19. People with an invulnerability bias perceive that they are unlikely to be infected and worry less about the infection, so risk behaviors may increase, increasing the probability of contagion and infecting others ³⁰30. Cabanillas-Rojas W. Conducta y propagación del COVID-19 en el Perú: Marco de referencia para el diseño de intervenciones conductuales de salud pública. doi: http://dx.doi.org/10.1590/scielopreprints.868.
https://doi.org/http://dx.doi.org/10.159... . Cognitive vulnerability assesses the risk of contagion, infecting others, as well as the risk of reinfection, while emotional vulnerability assesses fear, uncertainty, stress and feelings of sadness in the face of contagion and the pandemic.

The risk-protective behaviors dimension in the PCR-CV19 suggests that a high-risk perception would be related to an increase in protective behaviors against COVID-19 infection, which could have an important influence on the coronavirus transmission and could play a fundamental role in public health efforts ³¹31. Palacios M, Santos E, Velázquez M, León M. COVID-19, una emergencia de salud pública mundial. Rev Clin Esp. 2020;221(1):55-61. doi: 10.1016/j.rce.2020.03.001.
https://doi.org/10.1016/j.rce.2020.03.00... . In addition, the items in this dimension allow the evaluation of adherence to WHO guidelines to mitigate the spread of COVID-19 ²²22. Organización Mundial de la Salud. Consideraciones relativas a las medidas de salud pública y sociales en el lugar de trabajo en el contexto de la COVID-19. Anexo a las Consideraciones relativas a los ajustes de las medidas de salud pública y sociales en el contexto de la COVID-19. [Internet]. 2020. [Citado el 10 de mayo de 2020]. Disponible en: https://apps.who.int/iris/handle/10665/332084.
https://apps.who.int/iris/handle/10665/3... , where greater self-care and adherence to these guidelines could lead to a decrease in the rate of infection ¹⁵15. Shen Z, Zhong Z, Xie J, Ding S, Li S, Li C. Development and psychometric assessment of the public health emergency risk perception scale: Under the outbreak of COVID-19. Int J Nurs Sci. 2021;8(1):87-94. doi: 10.1016/j.ijnss.2020.12.012.
https://doi.org/10.1016/j.ijnss.2020.12.... ^,2828. Restrepo J. El concepto de riesgo: avances hacia un modelo de percepción de riesgo en salud. Psicoespacios. 2016;10(16): 174. doi: 10.25057/21452776.718.
https://doi.org/10.25057/21452776.718... ^,3030. Cabanillas-Rojas W. Conducta y propagación del COVID-19 en el Perú: Marco de referencia para el diseño de intervenciones conductuales de salud pública. doi: http://dx.doi.org/10.1590/scielopreprints.868.
https://doi.org/http://dx.doi.org/10.159... ^,3232. Otoya-Tono AM, García-Chabur MA, Jaramillo-Moncayo C, Campos Mahecha Ángela M. COVID-19: Generalidades, comportamiento epidemiológico y medidas adoptadas en medio de la pandemia en Colombia. Acta otorrinolaringol cir cabeza cuello [Internet]. 29 de mayo de 2020 [citado 11 de agosto de 2021];48(1):93-102. Disponible en: https://revista.acorl.org.co/index.php/acorl/article/view/519.
https://revista.acorl.org.co/index.php/a... .

The severity dimension in the PCR-CV19 is understood as the worst credible consequence resulting from COVID-19 infection and resulting in a loss ¹⁰10. Robles-Sánchez J. La Psicología de Emergencias ante la COVID-19: Enfoque desde la Prevención, Detección y Gestión Operativa del Riesgo. Clin Salud. 2020;31(2):115-8. doi: https://doi.org/10.5093/clysa2020a17.
https://doi.org/https://doi.org/10.5093/... . Therefore, the PCR-CV19 evaluates the perceived severity of death from COVID-19, complications of the disease ⁹9. Saletti-Cuesta L, Tumas N, Berra S. Percepción de riesgo ante el coronavirus en la primera fase de la pandemia en Argentina. Hacia Promoc Salud 2021; 26 (1): 163-178 doi: https://doi.org/10.17151/hpsal.2021.26.1.13.
https://doi.org/https://doi.org/10.17151... ^,2121. Rosero A, Carvajal J, Bolaños E. Percepción del riesgo frente al COVID-19 en adolescentes escolarizados colombianos. Universidad de Nariño, San Juan de Pasto, Colombia. Revista Boletín Redipe. 2021;10 (2): 201-217.⁾ and economic loss; while in other studies, such as the one by Germani et al. ²⁹29. Xiang, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, et al. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry. 2020;7(3):228-9. doi: 10.1016/S2215-0366(20)30046-8.
https://doi.org/10.1016/S2215-0366(20)30... , severity is evaluated in relation to anxiety or perceived severity in the event of becoming ill ²¹21. Rosero A, Carvajal J, Bolaños E. Percepción del riesgo frente al COVID-19 en adolescentes escolarizados colombianos. Universidad de Nariño, San Juan de Pasto, Colombia. Revista Boletín Redipe. 2021;10 (2): 201-217..

It should be noted that knowledge regarding the prevention of infection has been updated as knowledge of the virus has increased. Therefore, when the PCR-CV19 questionnaire is replicated, it is recommended that items should be modified in line with current scientific information, as reflected in the WHO guidelines.

The study has limitations in that the study population is older, not being able to account for the perception of risk in children or adolescents, and the lack of a statistical package to determine the PCR-CV19 index automatically.

The strength of the study is that, by defining the index in the compact interval, it can be characterized as a random variable and it will be the data, by means of statistical adjustments, that will provide evidence in favor of the best model, thus making it possible to find an adequate way of summarizing the data and the availability of inferential tools for the process of analysis and quantification of impacts or group comparisons.

One of the limitations of our study was that the study population was older, thus we were not able to evaluate the perception of risk in children or teenagers. Another limitation was the lack of a statistical package to determine the PCR-CV19 index automatically.

The strength of our study is that, by defining the index in the compact interval, it can be characterized as a random variable; and the data, by means of statistical adjustments, will provide evidence in favor of the best model, thus making it possible to find an adequate way of summarizing the data and the availability of inferential tools for the process of analysis and quantification of impacts or group comparisons.

In conclusion, the PCR-CV19 is considered as a valid and reliable instrument to assess the perceived risk of COVID-19 infection in the Colombian population, and could be adapted to different groups and contexts, through its four dimensions (cognitive vulnerability, emotional vulnerability, risk-protective behaviors and severity) that show theoretical and methodological coherence.

Acknowledgements:

Author José González thanks the Universidad de Playa Ancha and the support of the Ministry of Education through the Plan de Fortalecimiento de Universidades Estatales, UPA 1799.

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