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. Author manuscript; available in PMC: 2025 Nov 1.
Published in final edited form as: Clin Nurs Res. 2024 Sep 27;33(8):603–609. doi: 10.1177/10547738241282166

Psychometric Assessment of Anxiety Measures in a Pilot Study of African American Patients with Obstructive Sleep Apnea

La-Urshalar Brock 1, Katherine A Yeager 1, Andrew H Miller 2, Jordan Pelkmans 1, Ilana Graetz 3, Nicholas A Giordano 1
PMCID: PMC11812460  NIHMSID: NIHMS2026323  PMID: 39340150

Abstract

Background:

African American patient populations are disproportionately diagnosed with severe obstructive sleep apnea (OSA) compared to non-Hispanic white adults. Research suggests a link between OSA and anxiety. However, OSA and anxiety symptoms may present differently across minority groups. Research examining the reliability and validity of measures used to assess anxiety symptom severity in African American patient populations living with OSA are needed.

Purpose/Objective:

This pilot study evaluated the reliability and validity of the Patient Reported Outcomes Measurement Information System (PROMIS) Anxiety short form and the longer State-Trait Anxiety Inventory (STAI-S) in a sample of African American recently diagnosed with OSA.

Design, Setting, Sample:

In this cross-sectional pilot study, 32 prediabetic African American patients newly diagnosed with OSA were recruited from an academic sleep medicine clinic in the Southeastern United States to complete survey measures.

Measures:

Participants completed the 6-item PROMIS Anxiety short form and 20-item STAI-S.

Analysis:

Cronbach alphas assessed Internal reliability of measures and concurrent validity between measures was assessed using correlation coefficients (rs).

Results:

Both PROMIS Anxiety and STAI-S showed excellent internal consistency with Cronbach’s α >0.90. The PROMIS Anxiety T-scores and STAI-S scores were positively moderately correlated with each other (rs = 0.68; p<.0001), indicating concurrent validity.

Conclusions:

These results illustrate that both the PROMIS Anxiety and STAI-S scales have strong internal reliability in this sample of the African Americans with co-occurring OSA and prediabetes. The brief PROMIS Anxiety short form measure is validated to the longer STAI measure in this sample. An advantage of the PROMIS Anxiety scale is that it has a lower participant burden when completing questionnaires, contributing to a more refined approach to diagnosis and management when both OSA and anxiety coexist. These findings also underscore the importance of validating psychometric measures in marginalized populations, such as African Americans, who have often been underrepresented in psychometric research.

Keywords: obstructive sleep apnea, African American, anxiety, psychometrics, methods, clinical research areas

Background

Globally, approximately 1 billion adults experience obstructive sleep apnea (OSA), a sleep disorder caused by a partial or complete collapse of the airway which deprives the body of its normal oxygen saturation (Slowik et al., 2023). People living with OSA may experience interrupted sleep multiple times throughout the night. These disturbances in the sleep cycle lead to a host of difficulties, including unrefreshing sleep, excessive sleepiness, fatigue, diminished energy levels (Gottlieb & Punjabi, 2020; Senaratna et al., 2017), reduced work performance, sleepless-related accidents, compromised cardiovascular health, and an overall lower quality of life. (Diaz & Brown, 2016; Gottlieb & Punjabi, 2020; Slowik et al., 2023). OSA is associated with patients who have prediabetes or type 2 diabetes, and shares common risk factors including race, obesity, and age (Cass et al., 2013; Ceïde et al., 2015; Gottlieb & Punjabi, 2020). Moreover, beyond impacting sleep quality, OSA is intricately connected to an increase in mental health issues, which can lead to challenges in treatment adherence.

One such mental health issue that affects people with OSA is anxiety. Saunamaäki and colleagues (2007) conducted a review finding that individuals newly diagnosed with OSA frequently reported symptoms of depression and anxiety (Saunamaki & Jehkonen, 2007). Other research indicates that anxiety is more prevalent in patients with OSA when compared to the general population (Diaz & Brown, 2016; Kim et al., 2019; Shapiro et al., 2014). Yet, there is limited research targeted at the relationship between presence and burden of psychological symptoms, including anxiety, in patients who are newly diagnosed with OSA.

There is also a lack of targeted attention on the prevalence of undiagnosed and untreated OSA within minority populations (Johnson et al., 2022). The lack of attention to OSA in minorities can be attributed to several factors, including insufficient referrals for evaluation, delays in both evaluation and diagnosis, structural barriers such as transportation or work issues, limited awareness among primary care providers, and patients lost to follow up (Cass et al., 2013; Greenberg et al., 2004; Thornton et al., 2022). Studies have consistently revealed higher OSA prevalence rates among Asian, African Americans, and Hispanic individuals (Gottlieb & Punjabi, 2020; Johnson et al., 2022; Slowik et al., 2023), yet these populations and their relationships to OSA have remained underexamined. Teresi et al. (2016) found little difference between minority groups in the evaluation of the PROMIS Anxiety scale. However, recent studies suggest that OSA and anxiety might present differently in various minority groups due to psychosocial factors (Johnson et al., 2022). Manseau and Case (2014) found that there were large differences between non-Hispanic Black patients and White patients’ racial-ethnic visit prevalence ratios for anxiety, indicating that non-Hispanic Black patients were significantly less likely to seek treatment for anxiety compared to their White counterparts. This disparity could be attributed to various factors including cultural stigma or differences in health care access. For example, in a study of only non-Hispanic Black adults, a three-fold increase in the odds of being at risk for OSA was associated with anxiety (Ceïde et al., 2015). Unlike Teresi et al. (2016), this work assessed anxiety among African American patients with multiple chronic conditions that may face undue burden or challenges managing their symptoms.

Researchers studying anxiety rely on psychometric data to form and test theories, diagnose symptoms and develop treatments. The data they base their work on needs to be both reliable and valid. The above-mentioned differences in anxiety presentations in minority populations with multiple chronic conditions could alter self-reported data of tests that have not taken these differences into account, potentially rendering the data either unreliable, not valid or both. Therefore, the assessments researchers administer need to be rigorously vetted in order to ensure they are collecting accurate and consistent data on the population they are assessing. As rates of African American patients being diagnosed with severe OSA increases, it becomes imperative to thoroughly investigate the psychometric performance of instruments researchers are using to assess anxiety symptoms among this historically marginalized patient population, with the goal of improving OSA treatment adherence.

Purpose

The purpose of this study was to compare the psychometric performance, specifically reliability and validity, of the Patient Reported Outcomes Measurement Information System (PROMIS) Anxiety short form to the longer State-Trait Anxiety Inventory (STAI-S) in a sample of African American adult pre-diabetic patients who were recently diagnosed with OSA.

Methods

Design and sample

This is a secondary analysis of data collected from a pilot study. The pilot was funded by the National Institute of Nursing Research (NINR) to examine symptom severity and inflammatory presentations in African American adult patients with prediabetes and recent diagnosis of OSA (Giordano et al., 2023). Thirty-two participants were recruited from a sleep center located within a large urban academic medical center in the parent study within 30 days of being diagnosed with OSA (Giordano et al., 2023). Participants completed a collection of surveys capturing demographic data and symptom severity of anxiety at baseline. The Institutional Review Board of the urban academic medical center reviewed and approved this parent study (STUDY00002910).

Measures

PROMIS Anxiety (PROMIS® Item Bank v1.0 – Emotional Distress-Anxiety – Short Form 6a) assesses the level of emotional distress and anxiety of an individual. The 6-item questionnaire includes questions concerning the nature of the participant’s anxiety symptoms over the past 7 days, inquiring about fear, anxious misery, hyperarousal, and somatic symptoms of arousal. The PROMIS Anxiety instrument is based on a 5-point Likert scale (never, rarely, sometimes, often, always) that is summed across all questions into a raw score and then converted to a T-score; raw summed scores range from 6 to 30. The transformed scores are normed to a general population with a mean of 50 and standard deviation of 10 (Beleckas et al., 2018; Giordano et al., 2023; Pilkonis et al., 2011). Total scores range from 0 to 100; the higher the score, the more anxiety related symptoms being experienced by a respondent.

Study participants also completed the State-Trait Anxiety Inventory-State (STAI-S) inventory scale (20-item) (Gupta et al., 2016). STAI-S has 10 reverse-scored items (Zsido et al., 2020). Following the reversal of scores for positively-worded items, total scores are computed, ranging from 20 to a maximum of 80 on the STAI-S subscale (Kayikcioglu et al., 2017). STAI scores are often categorized as “no or low anxiety” (20-37), “moderate anxiety” (38-44), and “high anxiety” (45-80) (Kayikcioglu et al., 2017). The STAI-S is capable of measuring anxiety both in healthy individuals and individuals with known depression or anxiety (Knowles & Olatunji, 2020). Historically, the STAI-S has been shown to be both reliable and valid, though its reliability and validity has only been largely examined in predominantly white patient populations (Gupta et al., 2016).

Lastly, patient demographics and clinical characteristics were obtained from self-reported surveys and gathered from the medical records. Participants’ age, sex, Hgb A1c values (to detect prediabetes), and race were collected from the electronic medical records. Education levels were collected directly by participants via self-reported surveys.

Analyses

Descriptive statistical analyses were applied to summarize participant characteristics including the mean, median, and standard deviation for continuous variables and counts and percentages for categorical variables. A one sample t-test was calculated to compare the means of the PROMIS Anxiety in the sample to the known general population’s T-score of the PROMIS Anxiety scale. Spearman’s correlation coefficients evaluated the convergent validity between PROMIS Anxiety and STAI-S. Correlation coefficients were interpreted based on standard criteria where a value of 0.10 to 0.29 would be considered a weak correlation and 0.40 to 0.69 would be considered a moderate correlation between the PROMIS Anxiety and STAI-S scales (Schober et al., 2018). Reliability of PROMIS Anxiety and STAI was examined by calculating the Cronbach alpha for each measure; values greater than 0.70 are generally considered satisfactory for internal reliability (Clover et al., 2022; Mulhern, 2011; Taber, 2018). This pilot study was not designed to be powered to detect differences but was a hypothesis generating pilot. However, a sample size of N=32 provides sufficient power (80%) to detect even a small correlation (r=0.21). All analyses were conducted in R (R_Core_Team, 2023).

Results

This pilot study included 32 African American adult patients newly diagnosed with OSA of whom 53.1% were female. The mean age was 47.8 (± 8.8). Majority of patients (40.6%) were college graduates (Table 1). The sample’s A1c scores, averaging 5.97 (± 0.2), indicated the presence of prediabetes. Average PROMIS Anxiety scores were 46.0 (± 9.3) with 25.0% of participants scoring above 55, indicating higher than average anxiety symptoms (Table 1). The average STAI-S scores was 27.7 (± 10.3) and 18.8% scored greater than 37 on the scale revealed higher anxiety (Table 1).

Table 1.

Patient Characteristics (N= 32)

Age (in years), mean (SD) 47.8 (8.8)
Gender, n (%)
  Male 15 (46.9%)
  Female 17 (53.1%)
Marital Status, n (%)
  Divorced or separated 5 (15.6%)
  Married or partnered 13 (40.6%)
  Never married 14 (43.8%)
Education, n (%)
  Less than high school 1 (3.1%)
  High school or GED 8 (25.0%)
  Some college 10 (31.2%)
  College graduate 13 (40.6%)
Employment, n (%)
  Retired or Disabled 2 (6.2%)
  Unemployed 3 (9.4%)
  Working 27 (84.4%)
Most Recent A1c Score in Chart, mean (SD)1 5.97 (0.24)
OSA severity, n (%)2
  Mild 13 (44.8%)
  Moderate/Severe 16 (55.2%)
PROMIS Emotional Distress – Anxiety SF 6a v.1.0 (T-score calculation), mean (SD) 46.0 (9.2)
  Score > 55 – Heightened Anxiety Symptoms, n (%) 8 (25.0%)
State-Trait Anxiety Inventory (form Y-1) Total, mean (SD) 27.7 (10.3)
  Score > 37 – Heightened Anxiety Symptoms, n (%) 6 (18.8%)
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1

Missing 1 record

2

Missing 3 record

Both PROMIS Anxiety and STAI-S showed excellent internal consistency with Cronbach’s α of 0.93 (95% Confidence Interval (CI): 0.89, 0.96) and 0.94 (95% CI: 0.90, 0.97), respectively. When compared to less diverse samples, these values are comparable, as both measures typically show high internal consistency across various populations. Our results illustrate that both the PROMIS Anxiety and STAI-S scales have strong internal reliability in this sample of the African American population with co-occurring OSA and prediabetes. The PROMIS Anxiety T-scores and STAI-S scores were also moderately correlated with each other (rs = 0.68; p=<.0001), which indicates good concurrent validity of the brief PROMIS Anxiety measure to that of the longer STAI-S measure.

Discussion

Our analysis confirmed that both the PROMIS Anxiety short form and the STAI-S reached a threshold of acceptable internal reliability in a sample of prediabetic African American patients living with OSA. Anxiety symptoms are common among individuals with OSA, and the causes may vary between males and females and different ethnicities (Gharsalli et al., 2022; Gupta et al., 2016; Lee et al., 2015; Saunamaki & Jehkonen, 2007). It is crucial to assess and concurrently address psychological symptoms, particularly anxiety, to achieve optimal treatment outcomes for individuals with OSA. In this specific population of African American patients with newly diagnosed OSA, the PROMIS Anxiety scale and STAI-S also demonstrate concurrent validity.

The PROMIS Anxiety scale offers several advantages, including form versatility in administration, availability to use in multiple languages, and it has a lower participant burden when completing questionnaires, contributing to a more refined approach to diagnosis and management when both conditions coexist. These findings show that the short form six-item version of the PROMIS Anxiety scale can be used in a clinical care and research settings to accurately capture anxiety symptom severity among African Americans living with OSA.

Other studies have used the PROMIS or STAI-S to assess for anxiety and evaluate anxiety measure performance, some of which included African Americans but did not purposely center them in their research. Other researchers examining orthopedic populations and other chronic conditions have examined and shown the association of the PROMIS Anxiety measure, but they did not include large samples Black or African American patients (Beleckas et al., 2018; Cella et al., 2010). For instance, only 11.7% of participants in Beleckas et al. (2018) and 9% in Cella et al. (2010) were Black. Schalet and colleagues (2016) further showed the clinical validity of PROMIS Anxiety and other PROMIS measures in various longitudinal clinical groups such as major depressive disorder, cancer, chronic heart failure, back pain, and chronic obstructive pulmonary disease. However, the ethnicity of the participants in these groups was not disclosed. Though these studies contained a sub-sample of African Americans, to date no study has used the PROMIS Anxiety-short form 6a and the STAI-S scale to gauge the severity of anxiety symptoms solely among prediabetic African American patients with OSA. The fact that this study confirms the reliability and validity of the PROMIS Anxiety and the STAI-S when compared with each other is consistent with existing psychometric literature when looking at both instruments separately (Beleckas et al., 2018; Pilkonis et al., 2011). Our findings suggest that when nurse researchers and clinicians administer the PROMIS Anxiety short form or the STAI-S, results will be both reliable and valid among African American patient populations.

These findings also underscore the importance of validating psychometric measures in underrepresented populations, such as African Americans, who have often been underrepresented in psychometric research (Beard et al., 2011; Shrestha et al., 2020). Because the African American population has historically faced exclusion from such assessments, many cultural nuances in self-reporting have not been taken into account during the creation nor administration of these assessments. For example, significant stigmas are attached to members of the African American community who disclose that they suffer from anxiety or other mental health issues, this leads to hesitancy in seeking assistance due to fear of negative judgment or memories of past discrimination which results in under-reporting of anxiety (Hopkins & Shook, 2017; Shrestha et al., 2020; Williams et al., 2012). Other historical challenges, such as small sample sizes in minority-focused research studies, highlights the need to include understudied populations in research endeavors (Shapiro et al., 2014). This study enriches our understanding of the reliability and validity of the PROMIS Anxiety and STAI-S scales within a population that has historically faced exclusion from such assessments for various reasons. This awareness enhances the generalizability of these measures, paving the way for more inclusive and culturally sensitive mental health assessments in clinical and research settings in multiple areas.

The more researchers, clinicians, and nurses become aware of the cultural realities that affect their subjects or patients, the more accurate their data, diagnoses, and treatments will be. Studies such as this one, that test for the reliability and validity of mental health assessments when administered to minority populations inform both medical and scientific communities which mental health assessments report accurate and repeatable data. Researchers should carefully select and implement brief, psychometrically sound, and culturally appropriate assessment scales tailored to the unique characteristics and experiences of the individuals who are being assessed, in this case African Americans who are affected by OSA and anxiety. When nurses and clinicians working with minority communities can rely on assessments that include culturally appropriate questions, they gather culturally accurate data. This enables them to develop targeted interventions and strategies, ultimately improving overall health outcomes in minority communities.

When minority patients living with OSA and exhibiting anxiety are promptly and accurately diagnosed and their symptoms are properly managed they are more likely to experience a beneficial impact on sleep, comorbidities (e.g., pre-diabetes or hypertension) associated with OSA, and overall quality of life (Jackson et al., 2019). By assessing for anxiety when screening and managing African American patients for OSA, nurses and other clinicians can optimize referrals for appropriate symptom management, ensuring comprehensive care and improved outcomes for these patients. Additionally, addressing anxiety in conjunction with OSA management may lead to a better effect on treatment regimens, patient engagement, and quality of life (Diaz & Brown, 2016; Shapiro et al., 2014). Further research is needed across these areas.

Limitations

This pilot study has inherent limitations that warrant consideration. For example, the relatively small sample size of African American pre-diabetic individuals with OSA poses a potential limitation to the generalizability of the findings. Future research, with an expanded sample size, may yield a more robust psychometric dataset to evaluate the reliability and validity of anxiety measures, such as the PROMIS Anxiety and STAI-S, and contribute to a more comprehensive understanding of the co-occurrence of anxiety and OSA. Additionally, this work is cross-sectional. Introducing multiple time points for anxiety assessments, including pre- and post-treatment evaluations, would enable researchers to capture dynamic changes and measure responsiveness to change over time. Pre- and post-treatment evaluations would not only offer a more complete picture of anxiety symptom severity but also elucidate the impact of interventions on anxiety outcomes among individuals with OSA. Future research with other anxiety measurement tools, like Beck Anxiety Inventory (BAI) and Generalized Anxiety Disorder 7-item scale (GAD-7) should also be administered to prediabetic African American patients with OSA and compared to the PROMIS Anxiety and STAI-S measures, in order to evaluate their reliability and validity when assessing the anxiety of African Americans with OSA. Exploring subgroup analysis by gender or OSA severity in anxiety assessments could offer additional valuable insights into the accuracy of these measurements. Additional research is recommended to delve into the connection between being diagnosed with OSA and psychological symptoms utilizing reliable and valid measures to assess anxiety symptoms. Despite these limitations, this analysis is among the first to investigate the psychometric strength of the short form PROMIS Anxiety measure and the longer STAI-S measure in a sample comprised entirely of pre-diabetic African American patients newly diagnosed with OSA.

Conclusion

The current study expands upon prior psychometric research of both the PROMIS Anxiety and STAI-S scales by evaluating the reliability and validity of these tests when administered to a sample of pre-diabetic African American individuals with OSA. Anxiety symptom presentations among African American individuals with OSA remains insufficiently explored, largely due to under-diagnosis and limited research. While recent studies have enhanced understanding of the shared risk factors and relationships between individuals living with OSA and anxiety, less is known on which brief and psychometrically sound measures nurses can use to guide symptom management and referrals when caring for patients seeking OSA care. An advantage of the PROMIS Anxiety scale is that it has a lower participant burden when completing questionnaires, contributing to a more efficient approach to diagnosis and management when both conditions coexist. Findings from this research may lead researchers and clinicians to incorporate validated measures, such as the PROMIS Anxiety short-form and STAI-S, into routine practice and research studies, enabling quicker and accurate anxiety assessments in African American patients with OSA.

Table 2:

Reliability of Measures

Measure Cronbach’s Alpha 95% Confidence Interval
PROMIS Anxiety short form 6a 0.93 0.89–0.96
STAI-S 0.94 0.90-0.97
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Acknowledgments:

The authors thank the participants for their contributions and time. In addition, the authors thank the Center for the Study of Symptom Science, Metabolomics, and Multiple Chronic Conditions leadership and staff for their assistance.

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported in part by the National Institute of Nursing Research under award numberP30NR018090, the National Institute of Diabetes and Digestive and Kidney Diseases under award number P30DK111024, and the National Institute of Drug Abuse under award numberK23DA057415. The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health.

Footnotes

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article

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