https://doi.org/10.4081/hls.2026.14309
Cross cultural adaptation and psychometric validation of the Generalized Anxiety Disorder Assessment-7 for Urdu-speaking clinical populations
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Published: 4 June 2026
Anxiety disorders are a major public health concern in low- and middle-income countries due to the lack of culturally validated screening tools. Although the Generalized Anxiety Disorder Assessment-7 (GAD-7) is widely used, limited research exists on its cross-cultural psychometric validation in Pakistan. This study aimed to translate, culturally adapt, and psychometrically validate the GAD-7 in a Pakistani clinical population. Following a standard forward–reconciliation–backward translation procedure, the GAD-7 was translated into Urdu and reviewed by a multidisciplinary expert panel. The final version was administered to 267 participants. Exploratory and confirmatory factor analyses were conducted. Internal consistency and model fit indices were assessed. Criterion validity was evaluated using Receiver Operating Characteristic analysis. The adapted GAD-7 demonstrated high internal consistency (Cronbach’s α = 0.896). Confirmatory factor analysis indicated both models demonstrated excellent fit; however, one-factor model was retained as the more parsimonious solution. Factor loadings were statistically significant and within acceptable ranges. ROC analysis demonstrated excellent diagnostic accuracy (AUC = 0.970), with an optimal cutoff score of 10 yielding sensitivity of 98.6% and specificity of 81.4%. The Urdu GAD-7 is a reliable, valid, and clinically useful instrument for screening anxiety in Pakistani populations. While multidimensional representations may offer theoretical insight, the scale functions effectively as a unidimensional measure. The findings support its use in both clinical and research settings, particularly for early detection of anxiety in resource-limited contexts.
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1. Bie F, Yan X, Xing J, et al. Rising global burden of anxiety disorders among adolescents and young adults: trends, risk factors, and the impact of socioeconomic disparities and COVID-19 from 1990 to 2021. Front Psychiatry 2024;15:e1489427. DOI: https://doi.org/10.3389/fpsyt.2024.1489427
2. Liu X, Yang F, Huang N, et al. Thirty-year trends of anxiety disorders among adolescents based on the 2019 Global Burden of Disease Study. Gen Psychiatry 2024;37:e101288. DOI: https://doi.org/10.1136/gpsych-2023-101288
3. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol 1988;56:893-7. DOI: https://doi.org/10.1037/0022-006X.56.6.893
4. Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol 1959;21:50-5. DOI: https://doi.org/10.1111/j.2044-8341.1959.tb00467.x
5. Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006;166:1092-7. DOI: https://doi.org/10.1001/archinte.166.10.1092
6. Krizova K, Halamová J, Strnádelová B, Baránková M. Psychometric analysis of the GAD-7 questionnaire in Slovak helping professionals. J Affect Disord Rep 2024;17:100803. DOI: https://doi.org/10.1016/j.jadr.2024.100803
7. Ahmad S, Hussain S, Shah FS, Akhtar F. Urdu translation and validation of GAD-7: a screening and rating tool for anxiety symptoms in primary health care. J Pak Med Assoc 2017;67:1536-40.
8. Rahman R, Sheehan DV, Javed A, et al. The National Psychiatric Morbidity Survey of Pakistan: prevalence, socio-demographic and disability correlates. medRxiv 2024;1:1-23. DOI: https://doi.org/10.1101/2024.07.08.24310056
9. Sharif H, Sheikh SS, Thompson AM, et al. Prevalence of mental disorders among patients with multimorbidity visiting primary care settings in slums of Karachi, Pakistan. J Prim Care Community Health 2024;15:1-24. DOI: https://doi.org/10.1177/21501319241258658
10. Weaver LJ. Tension among women in North India: an idiom of distress and a cultural syndrome. Cult Med Psychiatry 2017;41:35-55. DOI: https://doi.org/10.1007/s11013-016-9516-5
11. Younas A, Zeb H, Arif I, et al. Sociocultural determinants of psychological distress and coping among South Asian individuals with chronic illness. Discov Psychol 2024;4:46-67. DOI: https://doi.org/10.1007/s44202-024-00148-z
12. Ahmad S, Hussain S, Akhtar F, Shah FS. Urdu translation and validation of PHQ-9, a reliable identification, severity and treatment outcome tool for depression. J Pak Med Assoc 2018;68:1166-70.
13. Beard C, Björgvinsson T. Beyond generalized anxiety disorder: psychometric properties of the GAD-7 in a heterogeneous psychiatric sample. J Anxiety Disord 2014;28:547-52. DOI: https://doi.org/10.1016/j.janxdis.2014.06.002
14. Müller F, Hansen A, Kube M, et al. Translation, cultural adaptation, and validation of the PHQ-9 and GAD-7 in Kinyarwanda for primary care in the United States. PLoS One 2024;19:e0302953. DOI: https://doi.org/10.1371/journal.pone.0302953
15. Fetters MD, Curry LA, Creswell JW. Achieving integration in mixed methods designs: principles and practices. Health Serv Res 2013;48:2134-56. DOI: https://doi.org/10.1111/1475-6773.12117
16. Zheng M. Conceptualization of cross-sectional mixed methods studies in health science: a methodological review. Int J Quant Qual Res Methods 2015;3:66-87.
17. Kumar R. Nursing research and statistics. New Delhi: Jaypee Brothers Medical Publishers; 2019.
18. Mundfrom DJ, Shaw DG, Ke TL. Minimum sample size recommendations for conducting factor analyses. Int J Test 2005;5:159-68. DOI: https://doi.org/10.1207/s15327574ijt0502_4
19. Wolf EJ, Harrington KM, Clark SL, Miller MW. Sample size requirements for structural equation models: an evaluation of power, bias, and solution propriety. Educ Psychol Meas 2013;73:913-34. DOI: https://doi.org/10.1177/0013164413495237
20. Memon MA, Ting H, Cheah JH, et al. Sample size for survey research: review and recommendations. J Appl Struct Equ Model 2020;4:1-20. DOI: https://doi.org/10.47263/JASEM.4(2)01
21. Ozolins U, Hale S, Cheng X, et al. Translation and back-translation methodology in health research: a critique. Expert Rev Pharmacoecon Outcomes Res 2020;20:69-77. DOI: https://doi.org/10.1080/14737167.2020.1734453
22. Hashmi AM, Naz S, Asif A, Khawaja IS. Urdu translation of the Hamilton Rating Scale for Depression: results of a validation study. Pak J Med Sci 2016;32:14-23. DOI: https://doi.org/10.12669/pjms.326.11399
23. Gheyle N, Jacobs T. Content analysis: a short overview. Intern Res Note 2017;10.
24. Piedmont R. Inter-item correlations. In: Michalos AC, editor. Encyclopedia of quality of life and well-being research. Dordrecht: Springer; 2014. p. 3303-4. DOI: https://doi.org/10.1007/978-94-007-0753-5_1493
25. Taber KS. The use of Cronbach’s alpha when developing and reporting research instruments in science education. Res Sci Educ 2018;48:1273-96. DOI: https://doi.org/10.1007/s11165-016-9602-2
26. Williams B, Onsman A, Brown T. Exploratory factor analysis: a five-step guide for novices. Australas J Paramed 2010;8:1-7. DOI: https://doi.org/10.33151/ajp.8.3.93
27. Li CH. Confirmatory factor analysis with ordinal data: comparing robust maximum likelihood and diagonally weighted least squares. Behav Res Methods 2016;48:936-49. DOI: https://doi.org/10.3758/s13428-015-0619-7
28. Moreno E, Muñoz-Navarro R, Medrano LA, et al. Factorial invariance of a computerized version of the GAD-7 across various demographic groups and over time in primary care patients. J Affect Disord 2019;252:114-21. DOI: https://doi.org/10.1016/j.jad.2019.04.032
29. Riglea T, Wellman RJ, Sylvestre MP, Sabiston C, O’Loughlin J. Factor structure and measurement invariance of the GAD-7 across time, sex, and language in young adults. J Affect Disord 2025;375:359-65. DOI: https://doi.org/10.1016/j.jad.2025.01.117
30. Ali BS, Reza H, Khan MM, Jehan I. Development of an indigenous screening instrument in Pakistan: the Aga Khan University anxiety and depression scale. J Pak Med Assoc 1998;48:261-78.
CRediT authorship contribution
Anwar Khan and Iftikhar Ali did the conceptualization of the study, conducted the literature review, synthesized the thematic findings, and developed the final draft of manuscript. Amalia Madihie supervised the research process, provided critical guidance, thoroughly reviewed the final draft, offered substantial technical input, and enhanced the academic rigor and clarity of the manuscript. All authors commented on previous versions of the manuscript. All authors read and approved the final version of the manuscript prior to submission.
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