TYPE Original Research

PUBLISHED 25 January 2023

DOI 10.3389/fpsyt.2022.989079

Psychometric properties of the

OPEN ACCESS Malay-version beck anxiety
inventory among adolescent
EDITED BY
Wan Nor Arifin,
Universiti Sains Malaysia Health
Campus, Malaysia

REVIEWED BY
students in Malaysia
Mahlagha Dehghan,
Kerman University of Medical Sciences, Iran
Sarita Sood, Nur Husna Ismail1 , Nik Ruzyanei Nik Jaafar1 ,
University of Jammu, India
Luke Sy-Cherng Woon1*, Manisah Mohd Ali2 , Rahima Dahlan3 and
*CORRESPONDENCE
Luke Sy-Cherng Woon Aimi Nur Athira Putri Baharuddin1
[email protected]
1
Department of Psychiatry, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia,
SPECIALTY SECTION 2
Faculty of Social Science and Humanities, Center for Research in Psychology and Human Wellbeing,
This article was submitted to Universiti Kebangsaan Malaysia, Bangi, Selangor, Malaysia, 3 Department of Psychiatry, Faculty of Medicine
Public Mental Health, and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
a section of the journal
Frontiers in Psychiatry

RECEIVED 11 July 2022 Background: The Beck Anxiety Inventory (BAI) is a common tool for screening anxiety
ACCEPTED 28 December 2022
PUBLISHED 25 January 2023
symptoms. In Malaysia, the Malay-version 21-item BAI has been previously validated
CITATION
in the Malaysian adult population. However, information regarding its reliability and
Ismail NH, Nik Jaafar NR, Woon LS-C, Mohd validity among adolescents below 18 years old is still lacking. The objective of
Ali M, Dahlan R and Baharuddin ANAP (2023) this study is to investigate the psychometric properties of the Malay-version BAI in
Psychometric properties of the Malay-version
beck anxiety inventory among adolescent
this population.
students in Malaysia. Methods: The Malay versions of the BAI and the Depression, Anxiety, and Stress Scale
Front. Psychiatry 13:989079.
doi: 10.3389/fpsyt.2022.989079
(DASS) were administered among a sample of lower secondary school students (n
= 329, age range: 13–14 years) in Selangor, Malaysia. Cronbach’s alpha value for
COPYRIGHT
© 2023 Ismail, Nik Jaafar, Woon, Mohd Ali, the internal consistency of the Malay-version BAI was determined. The correlation
Dahlan and Baharuddin. This is an open-access coefficient between the BAI score and DASS anxiety subscale score was calculated
article distributed under the terms of the to examine convergent validity. The factor structure of the Malay-version BAI was
Creative Commons Attribution License (CC BY).
The use, distribution or reproduction in other identified by exploratory factor analysis (EFA) using principal axis factoring.
forums is permitted, provided the original Results: The study included 329 respondents, who were predominantly female
author(s) and the copyright owner(s) are
credited and that the original publication in this (58.7%) and Malay (79.9%). The mean Malay-version BAI score was 14.46 (SD = 12.39).
journal is cited, in accordance with accepted The Malay-version BAI showed a high level of internal consistency (Cronbach’s alpha
academic practice. No use, distribution or = 0.948) and convergent validity with the DASS anxiety subscale score (r = 0.80, p <
reproduction is permitted which does not
comply with these terms. 0.001). The EFA suggested a one-factor solution, with the factor loading of all items
on the single factor ranging between 0.48 and 0.81.
Conclusion: The Malay-version BAI demonstrated good psychometric
properties. It can be a valid and reliable screening instrument for anxiety among
Malaysian adolescents.

KEYWORDS

adolescents, anxiety, factor analysis, psychometric, screening, Malaysia, validation study

Introduction
Anxiety disorders are among the most common mental health issues in the adolescent
population. Surveys showed many adolescents experienced anxiety and required treatment for
anxiety disorder (1). According to the World Mental Health Surveys, only 41.3% of the global
population meeting the criteria for an anxiety disorder thought they needed care (2). Anxiety
disorders among adolescents also cause an increased risk for suicidal behavior (3). In a study
by Windarwati et al. (4) among 869 high school adolescents, 72.7% of teens experienced anxiety
in the mild to very severe categories. The study also showed a significant relationship between

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Ismail et al. 10.3389/fpsyt.2022.989079

suicidal ideation with anxiety in adolescents. The Malaysian National panic components of anxiety. Borden et al. (17) preferred a five-
Health and Morbidity Survey (NHMS) (5) reveals that the mental factor solution consisting of subjective fear, somatic nervousness,
health condition of adolescents is increasingly worrisome, with many neurophysiological, muscular/motoric, and respiration. Specifically,
teenagers aged 13 to 17 years old found to be suffering from for adolescent populations, both Kumar et al. (11) and Steer et al. (12)
mental health problems. One in five people experienced depression favored a two-factor solution, representing subjective and somatic
(18.3%), two in five people suffered from anxiety symptoms (39.7%), symptoms of anxiety, respectively.
and about one-tenth experienced stress (9.6%). There was also an Mukhtar and Zulkefly (18) investigated the factor structure,
increasing trend for the prevalence of suicidal ideation to 10% reliability, and validity of the Malay-version BAI among Malaysian
compared to 7.9% in 2012. adults with a large sample of study participants (n = 1,090) with an
In Malaysia, a study that looked at the trends of mental health age range of 18 years to 63 years. In their exploratory factor analysis,
problems among children and adolescents based on three population- they found a three-factor solution (subjective anxiety, autonomic,
based surveys by Ahmad et al. (6) found that the prevalence of mental and neurophysiology) for the BAI, which accounted for 48.01% of the
health problems among children and adolescents aged 5 through 15 total variance. The BAI also demonstrated good internal consistency
years showed an increasing trend from 19.4% in 2006 and 20% in (Cronbach alpha coefficient = 0.91).
2011. Studies were also conducted among young adolescents aged Previous studies have demonstrated the original BAI as a reliable
13 to 17 whereby at this stage they experienced physical and/or and valid screening instrument for anxiety symptoms across different
emotional changes, and depression was one of the most common demographic sections, including among adolescents. It has been
mental health problems that could occur among them. successfully translated into the Malay version, which has also shown
Adolescents with anxiety problems experience considerable good psychometric properties. However, the validity and reliability
impact on their learning such as loss of interest in learning and of the Malay version BAI have yet to be examined among Malaysian
personality changes such as lethargy, low self-confidence or lack of adolescents. Furthermore, the BAI has displayed various factor
self-esteem. According to Nguyen et al. (7), 19.4% of students in structures in different populations. Therefore, in this study, we aimed
secondary school with low self-esteem were detected at a prevalence to examine the psychometric properties of the Malay version of BAI
of related to anxiety, depression, educational stress, and suicidal (Malay-BAI) among adolescents in Malaysia.
ideation. Hamid et al. (8) reported a moderate level of depression,
anxiety, and stress level for a total of 270 teenage students. The
authors suggested that those who suffered from depression, anxiety, Methods
and stress problems to be given clinical attention and mitigated before
becoming worse among students. Study design
According to Hein et al. (9) the most utilized method for
evaluating the presence of anxiety is by self-reporting questionnaires. This study was a part of a larger research project that aimed to
This method is easy to administer because respondents would only explore the role of social-emotional learning in improving mental
have to answer a list of related questions found in the inventory wellbeing among Malaysian adolescents. The current study was
provided. Among the questionnaires to measure anxiety is Beck’s conducted to support the development and validation of the learning
Anxiety Inventory (BAI). BAI, created by Aaron T. Beck and module. It was a cross-sectional survey of lower secondary school
colleagues, is a self-report inventory consisting of 21 items that students. Four schools were selected in the state of Selangor, Malaysia.
measure the severity of anxiety among adults and adolescents. Convenience sampling was carried out to select the schools and
Since items in BAI describe emotional, physiological, and cognitive recruited the participants in this study.
symptoms of anxiety but not depression, it can discriminate anxiety
from depression. Even though the instrument was initially applied
in the age range of 17–80 years old, it has also been used in peer- Participants
reviewed studies with younger adolescents aged 12 and older (10).
Two early studies examined the use of the BAI among The inclusion criteria were as follows: (1) first-year and second-
adolescents. The study by Kumar et al. (11) in an adolescent year secondary school students aged 13 and 14 years old; (2) students
psychiatric inpatient sample (aged 12–17 years) in Philadelphia, of government day schools; (3) provided informed consent; (4) able
United States found that the BAI displayed a high level of internal to comprehend the Malay language questionnaires. Students who
consistency (Cronbach’s alpha = 0.91). In another study by Steer underwent psychiatric/ psychological treatment were excluded from
et al. (12) among 105 outpatients aged between 13 and 17 years this study. This was ascertained by a simple screening question i.e.
at the same center, the BAI again demonstrated excellent internal “Have you received psychiatric/ psychological treatment in the past?”
consistency, with a Cronbach’s alpha value of 0.92. In a separate study in the demographic section of the questionnaire with 2 options, “Yes”
among adolescent inpatients, the BAI also displayed high internal or “No.” Using a subject-to-item ratio of 1:10 (19, 20), the minimum
consistency (Cronbach’s alpha = 0.94) and convergent validity with sample size required for the validation of the Malay version BAI
the Revised Children’s Manifest Anxiety Scale (13). was 210.
Various factor structures of BAI have been found. Beck et al. (14)
and Hewitt and Norton (15) supported similar two-factor models
corresponding to cognitive and somatic dimensions of anxiety. Instruments
These factors showed good internal consistency and test-retest
reliability. Subsequently, Beck and Steer (16) identified four factors The questionnaire used in this study contained three sections:
in the BAI reflecting subjective, neurophysiological, autonomic, and demographic data, the Malay-BAI, and the Malay version Depression,

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Ismail et al. 10.3389/fpsyt.2022.989079

Anxiety, and Stress Scale (Malay-DASS). The questionnaire was questionnaire. The actual time needed by the participants to answer
administered in the Malay language as Malay is the national language the questionnaire was approximately 10 to 20 min.
of Malaysia. Therefore, all students in Malaysian public secondary
schools, including those from minority ethnic groups such as Chinese
and Indians, possess basic proficiency in the language, which allowed Ethics approval
the universal application of the Malay-language questionnaire in this
study. Nevertheless, in a multi-ethnic country like Malaysia, methods Ethics approval was obtained from the Research Ethics
of socio-culture adaptation should be considered particularly in Committee of The National University of Malaysia (Approval No.:
adapting health status measures like BAI as highlighted by Beaton UKM PPI/111/8/JEP-2021-182).
et al. (21).

Statistical analysis
Demographic data
Participants filled up a demographic data sheet that covered In this study, the Statistical Package for the Social Sciences (IBM-
information on the personal background of participants (age, gender, SPSS R ) version 26.0 software was used for data analyses. Data were
race, and year of study) and their parents (parent occupation, parent checked for completeness. The normality of continuous data was
academic achievement, total parental income, and marital status). checked using the Kolmogorov-Smirnov test. Descriptive statistics
were generated for the sociodemographic variables and the scores
of the Malay-BAI and the Malay-DASS anxiety subscales, using
Malay-version beck anxiety inventory numbers and percentages for categorical variables, and medians and
The measure contains 21 items on anxiety symptoms. The interquartile ranges for the non-normally distributed continuous
symptoms were rated on a four-point scale. Scores range from 0 variables. Cronbach’s alpha was calculated for the internal consistency
to 63. A total score of 0 to 7 is considered minimal anxiety in of the Malay-version BAI. Spearman’s correlation coefficient between
range, 8–15 is mild anxiety, 16–25 is moderate anxiety, and 26–63 the BAI score and the DASS anxiety subscale score was calculated
is severe anxiety (22, 23). Mukhtar and Zulkefly (18) first validated to examine convergent validity. The factor structure of the Malay-
the Malay-version BAI for the Malaysian adult population using version BAI was identified by exploratory factor analysis (EFA) using
back-translating procedures by a team of content and linguistic principal axis factoring. All 21 items of the BAI were subjected to
experts whereby in the process, any word ambiguity and colloquial the analysis. The Kaiser-Meyer-Olkin (KMO) test was used to verify
differences were resolved for the overall suitability. sampling adequacy for the analysis, while Bartlett’s test was used to
check the suitability of the correlation structure for factor analysis. A
parallel analysis was conducted to determine the number of factors
to retain, using an online parallel analysis engine to generate random
Malay version of the depression anxiety stress scale
eigenvalues (25).
The instrument contains 21 items with three self-report scales
designed to measure the emotional states of depression, anxiety, and
stress. It was validated in the Malaysian population with Cronbach’s
alpha coefficients of 0.75 (depression), 0.74 (anxiety), and 0.79 (stress)
Results
by (24). The scale ranges from “did not apply to me at all” (0) Descriptive statistics
to “applied to me very much, or most of the time” (3). Subjects
responded to the items and the sub-score of the anxiety component A total of 329 participants responded to this study. Demographic
was used to compare with the BAI. The summed score of the DASS characteristics are shown in Table 1. The age was between 13 years
anxiety sub-scale (items 2, 4, 7, 9, 15, 19, 20) was used in this study. old (48.3%) and 14 years old (51.7%); 58.7% (n = 193) were female
and 41.3% (n = 136) were male. Malays formed the majority (61.7%).
The median score for the Malay-BAI was 11.0 (IQR = 16.5), while
Study procedure the median score for the Malay-DASS anxiety sub-score was 5.0 (IQR
= 6.5).
After obtaining informed consent from the parents of study
participants, the researchers received the contact information of the
students from the school counselors from each school involved in Internal consistency and convergent validity
this survey. The researchers then distributed the link to the online
survey form containing the demographic data section, Malay-BAI, The 21-item Malay-BAI displayed excellent internal consistency
and Malay-DASS to the participants via email and text messages. with a calculated Cronbach’s alpha value of 0.95. The Spearmen’s
Data collection was performed through live video conferencing in correlation coefficient between the Malay-DASS anxiety subscale and
five sessions to assist participants in answering the questionnaires. Malay-BAI indicated a strong positive correlation (Spearman’s Rho
Data collection lasted from August until October 2021 during the = 0.80) between the two measures, which was statistically significant
pandemic COVID-19. It took approximately 30 to 45 min in total (p < 0.001). This statistically significant strong relationship between
to complete the data collection process. This duration included time the Malay-BAI score and the Malay-DASS anxiety subscale score
to brief the participants about the study procedure, explain how to demonstrated convergent validity between these two measurements
answer the questions, and wait for the participants to submit the of the same construct, namely anxiety symptoms among the study

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TABLE 1 Socio-demographic of 329 respondents. TABLE 2 Factor loading and communality for the single-factor solution for
the 21-item BAI (N = 329).
Variable No. of respondents %
Factor loading
Age (year)
1 Communality
13 159 48.3
1. Rasa kebas Numbness or tingling 0.61 0.52
14 170 51.7
2. Rasa panas Feeling hot 0.63 0.55
Gender
3. Jalan terhuyung hayang Wobbliness 0.71 0.72
Male 136 41.3 in legs
Female 193 58.7 4. Sukar untuk bertenang/relaks 0.73 0.59
Unable to relax
Race
5. Takut sesuatu yang buruk 0.79 0.72
Malay 263 79.9
akan berlaku Fear of
Chinese 8 2.4 worst happening

Indian 56 17.0 6. Kepala pusing atau berat Dizzy 0.79 0.70

or lightheaded
Other 2 0.6
7. Debaran jantung meningkat Heart 0.77 0.65
Year of study (lower secondary) pounding/racing

First year 159 48.3 8. Rasa tidak stabil/tidak stabil 0.73 0.63
Unsteady
Second year 170 51.7
9. Cemas Terrified or afraid 0.79 0.67

10. Rasa amat takut Nervous 0.81 0.70.

participants. Meanwhile, the Malay-BAI score also displayed a
significant correlation with both the Malay-DASS depression subscale 11. Rasa tercekik Feeling of choking 0.69 0.61
(Spearman’s Rho = 0.72, p < 0.001) and stress subscale (Spearman’s 12. Tangan ketar Handstrembling 0.72 0.52
Rho = 0.75, p < 0.001), but with slightly lower values for the
13. Rasa bergoyang Shaky / unsteady 0.78 0.70
correlation coefficients.
14. Takut akan hilang kawalan Fear of 0.72 0.53
losing control

Exploratory factor analysis 15. Sesak nafas Difficulty in breathing 0.68 0.54

16. Takut seperti ingin mati Fear 0.51 0.36

The results of the KMO measure of sampling adequacy (=0.959) of dying
and Bartlett’s Test of Sphericity (p < 0.001) indicated that the data 17. Takut Scared 0.80 0.71
was suitable for factorial analysis (26). Inspection of the correlation
18. Perut tidak selesa Indigestion 0.78 0.68
matrix revealed no evidence of multicollinearity as none of the
bivariate correlation coefficients were > 0.80 (27). Furthermore, all 19. Pengsan Faint / lightheaded 0.48 0.54

items had a measure of sampling adequacy of above 0.80, which 20. Muka menjadi kemerahan Face 0.57 0.61
provided a good indication that the items were appropriate for flushed
inclusion in the factor analysis (26). Using the parallel analysis 21. Berpeluh bukan kerana panas 0.68 0.64
approach, the eigenvalues computed from the data were compared Hot/cold sweats
against randomly generated eigenvalues. In the comparison, only
the first eigenvalue based on the original data (10.546) was greater
than the random eigenvalue (1.478), while the second eigenvalue adolescent students. In this study sample, the Malay-BAI has
(1.334) was already smaller than the next random eigenvalue (1.391). demonstrated excellent internal consistency with a Cronbach’s of 0.95
Thus, the number of eigenvalues was one (28). This suggested and displayed good convergent validity with the anxiety subscale of
a one-factor solution to the Malay-BAI. Since there was only a the Malay-DASS. The EFA suggested a single-factor structure for
single factor, no rotation was performed. As shown in Table 2, the Malay-BAI.
the factor loadings of all BAI items on the single factor ranged The median score for the Malay-BAI in this study was 11.0
from the lowest of 0.48 (Item 19, “Faint / lightheaded”) to the (IQR = 16.5). In a study by Osman et al. (10) in an adolescent
highest of 0.81 (Item 11, “Nervous”). Meanwhile, the range of inpatient sample, the mean BAI score was 15.5 (SD = 12.7).
value for communality was between 0.36 (Item 16, “Fear of dying”) This was comparable to the mean BAI score (15.7, SD = 14.8)
and 0.72 (Item 3, “Wobbliness in legs” and Item 5, “Fear of reported by Jolly et al. (13) in another study among adolescent
worst happening”). inpatients. Similarly, the mean BAI score in an outpatient adolescent
study was 16.0 (SD = 12.6) (12). The average BAI score in the
current study was lower likely due to the community sample
Discussion involved in contrast to the clinical samples in the cited studies.
When compared with the finding from the validation study of
The purpose of this study was to investigate the psychometric the Persian version of the BAI among adolescents (mean =
properties of the Malay version of the BAI among Malaysian 8.0, SD = 6.9), our sample indicated a higher average level of

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Ismail et al. 10.3389/fpsyt.2022.989079

anxiety (29). Unfortunately, the average BAI score for Malaysian confirmatory factor analysis to further verify the factor structure of
adults in the community is unavailable for comparison, as the the Malay-BAI.
only known study utilizing the Malay-BAI (18) did not report
the value.
Concurring with previous research on the use of the BAI Conclusion
among adolescents, our study found that the BAI displayed excellent
internal consistency when administered to Malaysian adolescents. The Malay version of BAI has demonstrated excellent internal
The Cronbach alpha value (0.95) in the current study was better consistency and convergent validity when employed among
than the earlier validation of the Malay-BAI among adults (0.91) Malaysian adolescents. It also appeared to measure anxiety as a single
(18). Moreover, the Malay-BAI has shown very good convergent dimension in this sample. Findings from this study suggest that the
validity with the anxiety subscale of the Malay-version DASS Malay-version BAI can be a suitable instrument to screen for anxiety
scale, an instrument that has been validated in adolescents (30). in this population.
These findings suggest that the Malay translation of the BAI,
which was originally intended for use among adult respondents,
can be reliably administered to younger adolescents. There was Data availability statement
no indication that the language and content of the instrument
were hard for the study participants to comprehend and respond The raw data supporting the conclusions of this article will be
to appropriately. made available by the authors, without undue reservation.
The single-factor model of the BAI identified in this study is
different from most of the factor structures of the BAI found in
the existing literature. Various two-factor, four-factor, and five-factor Ethics statement
models have been reported (11, 12, 14–17). The Malaysian adult
study on the Malay-BAI proposed a 3-factor structure (subjective The studies involving human participants were reviewed and
anxiety, autonomic, and neurophysiology factors) (18). The study approved by Research Ethics Committee of The National University
by Osman et al. (10) among adolescent inpatients initially identified of Malaysia (Approval No.: UKM PPI/111/8/JEP-2021-182). Written
a four-factor solution. Nevertheless, their final analysis supported a informed consent to participate in this study was provided by the
single-factor structure, similar to the current study. The different participants’ legal guardian/next of kin.
factor models of the BAI could probably be explained by the
heterogeneity of the study population, differences in culture and
language between Malaysia and western countries, and different
Author contributions
understanding of anxiety symptoms between adults and adolescents.
NI, NN, and LW: conceptualization and methodology. NI
Even so, the unidimensional model of the Malay-BAI in this study
and AB: data curation. NI and LW: formal analysis. NI: project
does support its use as a measure of anxiety as a unitary construct
administration, resources, and writing-original draft. LW, NN, MM,
among adolescents.
and RD: supervision. NN: validation. LW and NN: writing-review
There were several limitations to this study. Since no diagnostic
and editing. All authors have read agreed to the published version
interview for clinical anxiety disorders was included, no reference
of the manuscript.
standard could be used to determine the concurrent validity,
sensitivity, and specificity of the Malay-BAI. Likewise, the cut-
off score for clinical anxiety using the Malay-BAI could not Funding
be decided in this sample by building a ROC curve. As this
study included non-Malay participants to be representative of This study was funded by the Trans-Disciplinary Research Grant
Malaysia’s diverse cultures, another possible study limitation was Scheme (TRGS) (Grant No. TRGS/1/2020/UKM/04/4) from the
the lack of cross-cultural adaptation. Subtle cultural differences
Ministry of Higher Education of Malaysia.
might necessitate further adaptations before the Malay-BAI is
administered to individuals of different ethnic backgrounds despite
the common understanding of the Malay language, to ensure Acknowledgments
content validity across cultures. This could be considered in
future research. The generalizability of the study findings to entire We would like to express our sincere gratitude to all students who
Malaysia might also be limited by the convenience sampling participated in this study and to school teachers for their assistance
method and sampling in the highly urbanized Selangor state alone. during data collection. We also convey our appreciation to the
Nonetheless, the demographic profile of our study sample contained original translators of the Malay-version BAI for permitting us to use
a good mix of both genders and the main ethnic groups in the the instrument in this study.
country, thus allowing wider application of the study results to
the Malaysian adolescent population to some extent. Despite these
limitations, to the authors’ knowledge, the present study is the Conflict of interest
first to investigate the psychometric properties of the Malay-BAI
in the range age below 18 years. Future research should strive to The authors declare that the research was conducted in the
further address the need for valid and reliable identification of absence of any commercial or financial relationships that could be
Malaysian adolescents with anxiety, including but not limited to a construed as a potential conflict of interest.

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Ismail et al. 10.3389/fpsyt.2022.989079

Publisher’s note organizations, or those of the publisher, the editors and the reviewers.
Any product that may be evaluated in this article, or claim that may
All claims expressed in this article are solely those of the be made by its manufacturer, is not guaranteed or endorsed by the
authors and do not necessarily represent those of their affiliated publisher.

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