Exploratory factor analysis for identifying CIEDs patients’ concerns during the Covid-19 pandemic in Europe

Interdisciplinary Description of Complex Systems 20(1), 50-56, 2022 EXPLORATORY FACTOR ANALYSIS FOR IDENTIFYING CIEDS PATIENTS’ CONCERNS DURING THE COVID-19 PANDEMIC IN EUROPE Bernadett-Miriam Dobai1, Laszlo Barna Iantovics1, *, Andreea Paiu2, and Dan Dobreanu1 1 George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures 1 Targu Mures, Romania 2 Transilvania University of Brasov 2 Brasov, Romania 1 DOI: 10.7906/indecs.20.1.7 Regular article Received: 14 May 2021. Accepted: 11 November 2021. ABSTRACT The current COVID-19 pandemic affects healthcare worldwide. Patients living with cardiac implantable electronic devices (CIEDs) are at high-risk to experience emotional distress and severe COVID-19 symptoms. Assessing their mental and physical health condition during the pandemic is crucial. An online questionnaire consisting of 45 multiple-choice questions regarding the patients’ emotional and physical status was completed by 210 CIEDs participants. On the eligible 184 responses, a principal axis factoring (PAF) multivariate analysis was performed, which is part of the Exploratory Factor Analysis (EFA) class, frequently used in healthcare research. The considered variables in the PAF were CIEDs patients’ concerns related to: device functioning, having received a shock (if ICD), the possibility to receive a shock (if ICD), access to medical care, reaching physicians, access to medication, getting infected by SARS-CoV-2, the health of caretakers, the health of their loved ones. However, one of the most difficult tasks in PAF is the selection of an appropriate number of factors. We proposed three rules to be considered, the verification of: the Kaiser criterion, the Cattell’s Scree test, and the cumulative variance (to explain at least 60-65 %). After the number of factors had been established, we proposed a final verification, the Monte Carlo Parallel Analysis. Two factors were identified, subsequently defined as “Healthcare-related concerns” and “Fear of COVID-19 disease”, which explained 75.56% of the cumulative variance. The factors highlight the need for accurate medical information provision, patient education, and support to improve healthcare during the pandemic. KEY WORDS exploratory factor analysis, SARS-CoV-2, cardiac implantable electronic devices, healthcare-related concerns, Industry 4.0 CLASSIFICATION JEL: I10 PACS: 02.50.-r, 12.40.Ee. *Corresponding author, : ; -; *Gh. Marinescu, 38, Târgu Mureș, Mureș, 540142, Romania Exploratory factor analysis for identifying CIEDs patients’ concerns during the Covid-19 … INTRODUCTION Worldwide, both physical and mental health has been affected by the current COVID-19 pandemic [1]. Cardiac implantable electronic devices (CIEDs), such as pacemakers, implantable cardioverter-defibrillators (ICD), cardiac resynchronization therapies, are standard of care in life-threatening arrhythmias, and device implantation rates show a yearly increase [2, 3]. Individuals living with CIEDs not only have multiple underlying diseases, but also experience quality of life changes [4-6]. These patients are vulnerable to get severe COVID-19 symptoms and to develop emotional distress. Therefore, an online purpose designed questionnaire was developed to assess their physical and mental health condition during the pandemic. In the current paper, a multivariate analysis based on a principal axis factoring (PAF) was performed focusing on CIEDs patients’ concerns related to: device functioning, having received a shock (if ICD), the possibility to receive a shock (if ICD), access to medical care, reaching physicians, access to medication, getting infected by SARS-CoV-2, health of caretakers, health of patients’ loved ones. PAF is part of the Exploratory Factor Analysis (EFA) class, which is frequently used in healthcare research [7-10]. One of the most difficult problems in EFA lies in the identification of the optimal number of factors [11-14], as an inappropriate number of factors may lead to imprecise conclusions. A previous paper [15] highlighted the importance of the total cumulative variance explained by the factors in the establishment of the appropriate number of factors. It was proved that, at least, a threshold value of cumulative variance should be explained by the extracted factors, considering the specificity of the research. Based on the mentioned previous research, and on a thorough scientific literature review, we propose three rules to be considered in selecting the best-fitted number of factors, as well as an additional rule, for verification purposes, of the selected number of factors. MATERIAL AND METHOD A purpose-designed questionnaire containing 45 multiple choice questions was created to assess CIED patients’ mental concerns and physical health condition during the COVID-19 pandemic. The questionnaire was completed online, anonymously and voluntarily by 210 CIEDs patients from the outpatient care of the Institute for Cardiovascular Emergencies and Transplant and by international patients, as part of online support groups mainly from the USA, UK, Hungary, Canada. Eighteen participants were excluded due to contradictory responses. The final data analysis included 184 responses. The varimax method for rotation in EFA was proposed by Kaiser, which is one of the most frequently used methods of rotation [16]. PAF was performed, applying the varimax orthogonal rotation method focusing on the concerns of the respondents. Initially, the study included 9 variables (Var): Var1- device functioning, Var2- having received a shock (if ICD), Var3- the possibility to receive a shock (if ICD), Var4- access to medical care, Var5- reaching physicians, Var6- access to medication, Var7- getting infected by SARS-CoV-2, Var8- health of caretakers, Var9- health of their loved ones. A preliminary study excluded Var3, Var9 due to their low variability. Further communality analysis excluded Var1, Var2, and Var8. The exclusion of Var2 and Var3 is explained theoretically by the fact that these concerns may arise only for patients with ICD, not for every CIED patient assessed in the current study. PAF was performed on the remaining variables: Var4, Var5, Var6, Var7. 51 B.M. Dobai, L.B. Iantovics, A. Paiu and D. Dobreanu Based on an in-depth study of the scientific literature, and considering the results of the research mentioned anteriorly [15], we suggest the following three rules to determine the number of extracted factors:  rule 1): the total explained variance to be at least 60 %-65 % – established since none of the variables passed the normality assumption,  rule 2): the extracted eigenvalues to be at least 1, criteria proposed by Kaiser [16],  rule 3): visual interpretation of the Scree plot, called as Cattell’s Scree test [17]. Parallel analysis (PA) was proposed by Horn, named as the Monte Carlo simulation method, useful to determine the number of factors, which should be extracted in EFA [18]. One (...truncated)