QJM: An International Journal of Medicine, 2024, 117(1), 38–47

https://doi.org/10.1093/qjmed/hcad224
Advance Access Publication Date: 3 October 2023
Original Article

Downloaded from https://academic.oup.com/qjmed/article/117/1/38/7288193 by UERJ - Universidade do Estado do Rio de Janeiro user on 11 March 2024
Psychometric properties and observational data for
COVID-19 Yorkshire Rehabilitation Scale (C19-YRSm) for
post-COVID-19 syndrome
L. Kustura1, D. Bobek2, A. Poljic �anin3,4, S. Pavelin5, M. Buljuba� �
� Soda
sic 6 �
, J. Soda 7
, J. Aksentijevic �2,
K. Duka Glavor8,9, N. Naranc � Knez8, V. Viali10, A. Cukrov11, I. Todoric
�ic � Laidlaw12, N. Ipavec13, D. Vukorepa1,
I. Stipica14, K. Bakrac�15, B. Bo�
skovic�16, A. Mastelic�17, N. Rez � Muz
� ic �17, A. Markotic
�inic �17, Z. -Doga�
s18,19,
20,21 18,�
K. Dolic� �
and M. Rogic Vidakovic �
1
Department of Psychiatry, University Hospital of Split, Split, Croatia
2
Department of Physical and Rehabilitation Medicine with Rheumatology, Dubrava University Hospital, Zagreb, Croatia
3
Department of Physical Medicine and Rehabilitation with Rheumatology, University Hospital of Split, Split, Croatia
4
Department of Health Studies, University of Split, Split, Croatia
5
Department of Neurology, University Hospital of Split, Split, Croatia
6
Department of Pediatrics, University Hospital of Split, Split, Croatia
7
Department of Marine Electrical Engineering and Information Technologies, Signal Processing, Analysis, and Advanced Diagnostics Research and Education
Laboratory (SPAADREL), Faculty of Maritime Studies, University of Split, Split, Croatia
8
Department of Neurology, General Hospital Zadar, Zadar, Croatia
9
Department of Health Studies, University of Zadar, Zadar, Croatia
10
Family Medicine Vanja Viali, Split, Split-Dalmatia County, Croatia
11
Primary/Family Care Office, Slunj Community Health Centre, Slunj, Croatia
12
Department for Forensic Psychiatry, University Psychiatric Hospital Vrapc �e, Zagreb, Croatia
13
Department for Transfusion Medicine, University Hospital of Split, Split, Croatia
14
Department of Family Medicine, University of Split School of Medicine, Split, Croatia
15
Institute of Emergency Medicine, Split-Dalmatia County, Split, Croatia
16
Department of Otorhinolaryngology, Head and Neck surgery, University Hospital of Split, Split, Croatia
17
Department of Medical Chemistry and Biochemistry, University of Split School of Medicine, Split, Croatia
18
Department of Neuroscience, Laboratory for Human and Experimental Neurophysiology (LAHEN), School of Medicine, University of Split, Split, Croatia
19
Sleep Medicine Centre, University Hospital of Split, Split, Croatia
20
Department of Interventional and Diagnostic Radiology, University Hospital of Split, Split, Croatia
21
Department of Radiology, University of Split School of Medicine, Split, Croatia

�Address correspondence to Dr M. Rogic � Vidakovic�, Department of Neuroscience, Head of Laboratory for Human and Experimental Neurophysiology (LAHEN),
�
University of Split School of Medicine, Split, Croatia, Soltanska 2, 21000 Split, Croatia. email: maja.rogic@mefst.hr

Summary
Background: The recently developed modified COVID-19 (coronavirus of 2019) Yorkshire Rehabilitation Scale (C19-YRSm) captures com­
prehensive biopsychosocial components of WHO’s International Classification of Functioning, Disability, and Health related to the Long
Covid or post-COVID syndrome. The scale response categories on C19-YRSm were done post hoc on data collected from the original ver­
sion of C19-YRS.
Aim: To evaluate the C19-YRSm scale using reliability and validity measures.
Design: Prospective, observational study.
Methods: The study includes 369 patients (clinical group) and 426 subjects of the general population (control group) and captures their
post-COVID-19 symptoms. In addition, the reliability of C19-YRSm was estimated by Cronbach’s alpha coefficients of internal consistency
and inter-item correlations for subscales (‘Symptom severity, Functional disability, and Other symptoms’). Convergent validity was estab­
lished using correlations between C19-YRSm and Fatigue Severity Scale (FSS). The incremental validity of C19-YRSm was measured by in­
troducing a hierarchical regression model using the C19-YRSm ‘Overall health’ subscale and FSS as criterion variables.
Results: C19-YRSm subscales have excellent internal consistencies (Cronbach’s a value 0.81–0.96) and acceptable inter-item correlations
(r value 0.23–0.79). Hereafter, the convergent validity of the C19-YRSm is good due to significant correlations between C19-YRSm subscales
and FSS and C19-YRSm subscales. Finally, the hierarchical regression analysis supported consistent evidence for the incremental validity
of the C19-YRSm subscales.
Conclusion: C19-YRSm is a reliable and valid self-assessment scale for the assessment of post-COVID-19 syndrome.

Received: 14 June 2023. Revised (in revised form): 14 September 2023.

# The Author(s) 2023. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved.
For permissions, please email: journals.permissions@oup.com

Introduction
During the COVID-19 (coronavirus of 2019) pandemic, 765 million
people worldwide have been infected with severe acute respira­
tory syndrome coronavirus 2, which caused the death of 7 million
people.1 Many individuals suffering from COVID-19 have
reported persistent symptoms or complications lasting beyond 4–
12 and >12 weeks, which were termed as ongoing symptomatic
COVID-19 or post-COVID-19 syndrome, respectively.2–4 Follow-
up studies of COVID-19 subjects indicated that 50–80% of
patients who recovered from COVID-19 reported symptoms, such
as fatigue, headache, dyspnoea, anosmia, and memory difficul­
ties.3,5–10 Post-COVID-19 is regarded as a complex and multifac­
torial syndrome involving virus-specific pathophysiological
response leading to the elevation of interferons and inflamma­
tory cytokines, lymphocyte activation and dysregulation and
chronic myeloid cell activation.11,12 Patients themselves intro­
duced the term ‘long COVID’, describing all the symptoms they
could experience after suffering from COVID-19.13 COVID-19-
related symptomatology has been more pronounced in individu­
als with severe disease. However, it has also been noticeable in
individuals with mild and moderate disease.5,14,15 Symptoms
may be newly occurred following initial recovery from an acute
COVID-19 episode or persist from the initial illness, with symp­
toms fluctuation or relapse over time.4
It has been proposed that the wide range of post-COVID-19
symptoms should be carefully interpreted as clinical symptom­
atology with the individual profiling of the immune
system.3,9,16,17 The National Institute for Health and Care
Excellence (NICE) called for developing and validating instru­
ments to assess post-COVID-19. Therefore, in October 2021, the
World Health Organization (WHO) developed a clinical case defi­
nition of post-COVID-19 conditions by Delphi methodology, in­
cluding 12 domains, available for use in all settings.4,18 So far,
several instruments have been developed for monitoring post-
COVID-19 symptoms, and their effect on life quality, including
post-acute (long) COVID-19 quality of life (PAC-19QoL) instru­
ment,19 the Long COVID Symptom and Impact Tools for monitor­
ing the symptoms and impact of Long COVID,20 the Symptom
Burden Questionnaire for Long Covid (SBQ-LC),21 and the most
recently validated test called modified COVID-19 Yorkshire
Rehabilitation Scale (C19-YRSm)22 for Long Covid or post-COVID-
19 syndrome.
The C19-YRSm scale has been developed as the first patient-
reported outcome measure for post-COVID-19 syndrome, captur­
ing all aspects of the 2001 WHO International Classification of
Functioning, Disability, and Health framework (ICF).4,18,22,23
Therefore, a condition-specific patient-reported C19-YRSm cap­
tures the common symptoms, functional disability and overall
health of patients with post-COVID-19. The C19-YRSm is recom­
mended by NICE and National Health Service (NHS) England
service guidance for post-COVID-19.22,24,25 However, the scale
C19-YRSm response categories were done post hoc on data
collected from the original version of C19-YRS,26,27 omitting the
psychometric properties of prospectively collected data on the
new scale C19-YRSm.22
Therefore, this prospective cross-sectional study aimed to test
the psychometric properties of C19-YRSm using reliability statis­
tics, convergent, concurrent and incremental validity measures
in a sample of patients (clinical group) and subjects of the gen­
eral population (control group). The reliability of C19-YRSm was
estimated by Cronbach’s alpha coefficients of internal consis­
tency and inter-item correlations for C19-YRSm subscales
(Symptom severity, Functional disability and Other symptoms).
L. Kustura et al. | 39
Convergent validity was established using correlations between
C19-YRSm and the Fatigue Severity Scale (FSS).28 The incremen­
tal validity of C19-YRSm was measured using the C19-YRSm
Overall health subscale and FSS as criterion variables.
Materials and methods
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Study participants
This prospective, observational study includes the patients (clini­
cal group) and the general population (control group) experienc­
ing post-COVID-19 symptoms.
An online survey for reaching the control group of subjects
was conducted from 13 February to 22 March 2023, and a total of
2762 participant responses were collected.
The patients in the clinical group were recruited from a
community-based post-COVID clinic within the Croatian’s capi­
tal city area (the City of Zagreb and Zagreb County) (Dubrava
University Hospital, Zagreb), Split-Dalmatia County (University
Hospital of Split) and Zadar County (General Hospital Zadar). An
online survey for the clinical group was conducted from 17
February to 1 April 2023, and a total of 432 patient responses
were collected. The participants were excluded based on the fol­
lowing criteria: technical error (i.e. duplicates), pregnant women,
a person under 18 years of age (minor), a person with psychiatric
disease, COVID-19 not confirmed with antigen or PCR tests and a
person infected with COVID-19 <3 months ago.
In selecting accessible samples, a reduction sample strategy
was applied to 2762 subjects from the control group. Since the
subject’s age is an important predictor of a patient’s overall
health,29,30 and the variable may influence the significance of the
results, the control group sample was stratified by age. Subjects
were first stratified into two groups, under and over 50, and sub­
jects under 50 were randomly excluded. After applying exclusion
criteria and reduction sample strategy, a total number of 426 par­
ticipants in the control group and 369 participants in the clinical
group were included in the analysis. Figure 1 depicts the recruit­
ment diagram and exclusion criteria for both groups, with an ap­
plication of the reduction sample strategy in the control group.
Study protocol and instrumentation
Both groups completed the online survey comprising two ques­
tionnaires, the modified COVID-19 Yorkshire Rehabilitation Scale
(C19-YRSm)22 assessing the post-COVID symptoms and FSS31
capturing fatigue severity. The data were separately collected
and accessible only to the researchers. The participants evalu­
ated their symptomatology on both scales in the last 7 days. If
participants had COVID-19 more than once, the questions about
symptoms referred to their last COVID-19. Additionally, demo­
graphic, disease-related, and COVID-19-related variables were
collected. Demographic information included the following vari­
ables: age, sex, height, weight, body mass index (BMI), educa­
tional level, working status, comorbidity and medication history.
The COVID-19-related questions included: the number of times a
person had COVID-19 asymptomatic or symptomatic (once,
twice, three times and more than three times); the last time the
person got COVID-19 asymptomatic or symptomatic (<1 month
ago; 1–3 months ago; 3–6 months ago; 6–12 months ago; 12–
24 months ago; and >24 months ago); the severity of the COVID-
19 (asymptomatic, symptomatic, severe clinical picture—
‘temperature above 39 degrees Celsius, breathing difficulties,
hospital admission’); and confirmation of COVID-19 disease by a
positive antigen or PCR test.
40 | QJM: An International Journal of Medicine, 2024, Vol. 117, No. 1
Figure 1. Recruitment diagram, exclusion criteria and stratification strategy for clinical and control group. Clinical group (upper view), and control
group (lower view).
The modified COVID-19 Yorkshire Rehabilitation Scale
(C19-YRSm)
The original COVID-19 Yorkshire Rehabilitation Scale (C19-
YRS)26 was developed as a 22-item patient-reported outcome
measure that grades the severity of symptoms, functional dis­
ability, overall health and additional symptoms on an 11-point
numerical rating scales. The psychometric properties were deter­
mined in a sample of 187 patients with post-COVID, showing
good reliability overall (Cronbach’s alpha 0.891) and for individ­
ual subscales.27 Preliminary testing of the C19-YRS in 370
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community patients revealed three clinical severity phenotypes
(mild, moderate and severe) for individual symptoms and func­
tional disability.32 Since dysfunctional scale response categories
were observed by preliminary Rasch analysis of the original
version of C19-YRS, the scale was modified. This new modified
version, C19-YRSm, differed from the original by changing the
11-point Likert scale with a 4-point scale (0–3).22 The C19-YRSm
consists of 17 items divided into four subscales concerned with
the ‘severity of symptoms, functional limitation, other symp­
toms’ and ‘overall health’. The symptom severity subscale

consists of 10 items (Questions 1–10) (Score 0–30). The functional
disability subscale consists of five items (Questions 11–15) (Score
0–15). The other symptoms subscale represents Question 16
(Score 0–25), and the fourth subscale, termed the overall health,
represents Question 17 (Score 0–10). Zero scores represent symp­
toms not present, Score 1 represents a mild problem (not affect­
ing daily life), Score 2 moderate problem (affecting daily life to a
certain extent) and Score 3 represents a severe problem (life-dis­
turbing problem or affecting all aspects of daily life). The patients
can also indicate their other symptoms not listed under the sub­
scale ‘Other symptoms’.
Permission to use the C19-YRSm and translation and
cultural adaptation of the C19-YRSm
The authors of the study obtained an academic/research licence
from the University of Leeds IP LIMITED, a company registered in
England and Wales with company registration number 4582496,
whose registered office is The Company Secretariat, 11.75 E C
Stoner Building, University of Leeds, Leeds, West Yorkshire LS2
9JT, England (‘Leeds’) for the use of the Product (as defined in this
Licence). The authors obtained permission to proceed with the
translation and will send a copy of the translated version to the
University of Leeds and the validation certificate behind the
translation upon the publication of this work.
The C19-YRSm was translated into Croatian following existing
recommendations, methodological approaches and guidelines in
translating, adapting and cross-validating instruments.33 Two
authors of this study (M.R.V. and L.K.), and one independent
Professor of the Croatian language (Professor Daria Matijevic �), all
native Croatian speakers, translated the C19-YRSm question­
naire from English to Croatian. Next, the English language profes­
sor (D.B.) compared translated versions of C19-YRSm in Croatian
and produced the final version of the questionnaires. Another in­
dependent English language professor (University of Split) who
had no insight into the original English version translated the last
Croatian version of the questionnaires back into English, com­
pleting the final adaptation of the Croatian version of C19-YRSm
used in the proposed study.
Fatigue Severity Scale
The FSS30 is a nine-item self-report questionnaire used to assess
fatigue during the past week. The grading for each item ranges
from 1 to 7, where 1 indicates complete disagreement and 7 indi­
cates strong agreement. The scoring is calculated by adding up all
the answers and dividing them by nine (average value). A cut-off
score of �4 and �5 for clinically relevant fatigue was used.34–36
Psychometric properties of the FSS scale were previously con­
ducted in the Croatian population of patients with multiple sclero­
sis disease (N ¼ 179) and healthy control subjects (N ¼ 999).28 The
Croatian version of the FSS has excellent internal consistency
(Cronbach’s a value 0.93) and unidimensional structure estimated
by factor analysis. The concurrent validity of the FSS is satisfac­
tory due to the significant differences between people with multi­
ple sclerosis and control subjects (P < 0.05).
Tests of reliability and validity
The reliability of the C19-YRSm questionnaire was estimated by
Cronbach’s alpha (a) coefficients of internal consistency and
inter-item correlations for each subscale (‘Symptom severity,
Functional symptoms, and Other symptoms’). Overall, health
was considered as a separate generic question of health status.
The correlation metric between C19-YRSm subscales and FSS
scale demonstrated convergent validity. Fatigue is a common
symptom in people recovering from COVID-19. Recently, the FSS
L. Kustura et al. | 41
scale has been validated in patients recovering from COVID-19.37
Concurrent validity of C19-YRSm subscales was assessed by
comparing the control and clinical groups. The incremental va­
lidity of C19-YRSm subscales was assessed by the hierarchical re­
gression model using the subscale ‘Overall health’ and FSS as
criterion variables. Age, sex, BMI and chronic disease were in­
cluded in the first step, while the scores on C19-YRSm subscales
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were added in the second step.
Statistical analyses
Parameters of skewness, kurtosis and normality test (Kolmogorov–
Smirnov test) indicated deviations from a normal distribution for
C19-YRSm subscales and the FSS scale. Further, the Mann–
Whitney U test (Z) and Student’s t-test were used for ordinal and
continuous variables. Univariate analysis was performed using the
Chi-square test (v2) for categorical variables. Also, correlation anal­
yses were conducted using Pearson’s r coefficient (r, rpb) and
Spearman rank-order correlation (q).
Descriptive statistics of relevant participants’ characteristics
and applied scales were summarized by N, percentage, mean and
standard deviations, median and interquartile range. Psychometric
properties were examined by estimating internal consistency, inter-
item correlations, convergent, concurrent and incremental validity
of the C19-YRSm subscales. The general Regression Models module
was applied. In all calculations, a P-value of <0.05 was considered
statistically significant. Data analysis was performed using the
Statistica 12 software.
Results
Demographic, disease-related data, and
C19-YRSm and FSS results
Table 1 shows the characteristics of 426 subjects in the control
group and 369 patients in the clinical group. The Supplementary
Material contains other relevant demographic information on
the county of living, education, working status, comorbidities
and medication. In total, 75.35% of subjects in the control group
and 53.92% of patients in the clinical group were female. The
subjects in the control group were between 20 and 79 years old
with a mean age of 56.50 (±8.17) years, and in the clinical group
range was 21–90 years with a mean age of 57.84 (±14.65). No sig­
nificant difference was found in age (t(793) ¼ −1.61; P ¼ 0.11) be­
tween the two groups of subjects. Participants in the clinical
group had significantly more chronic diseases (v2¼42.38;
P < 0.001) and used more medication (v2¼44.21; P < 0.001) than
subjects in the control group (Supplementary Tables S1 and S2).
Moreover, patients in the clinical group had significantly more
severe COVID-19 (v2¼218.7; P < 0.001) (Table 1). Most subjects
from the clinical group got over COVID-19 over 12 months ago
and more than 24 months ago, while subjects in the control
group got over COVID-19 more than 6 months ago and
<24 months ago. No significant difference was found in the num­
ber of COVID-19 infections between groups of subjects (v2¼2.83;
P ¼ 0.09). Most of the subjects from both groups have gotten over
COVID-19 once. However, in the clinical group of subjects, signifi­
cantly lower ‘Overall health’ (Z¼−2.17; P ¼ 0.02); and more ‘Other
symptoms’ (Z¼−2.00; P ¼ 0.04) was found in subjects that have
gotten over COVID-19 two or more times (Table 1).
Table 1 shows the median values of the C19-YRSm scale for
both groups. Significantly higher ‘Symptom severity’ (Z¼−10.15;
P < 0.001), ‘Functional disability’ (Z¼−7.96; P < 0.001) and ‘Other
symptoms’ (Z¼−2.48; P < 0.05) are found for the clinical group
compared to the control. Moreover, ‘Overall health’ was signifi­
cantly lower for clinical group subjects (Z ¼ 7.13; P < 0.001).
42 | QJM: An International Journal of Medicine, 2024, Vol. 117, No. 1

Table 1. Characteristics of study participants in control and clinical group

Control (N ¼ 426) Clinical (N ¼ 369)

Age, years (mean±SD) 56.50 ± 8.17 57.84 ± 14.65

Age (range) 20–79 21–90
Female (n,%) 321, 75.35 199, 53.92
Height, cm (mean±SD) 172.44 ± 8.87 170.90 ± 8.93

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Weight, kg (mean±SD) 77.65 ± 14.77 85.85 ± 18.10
BMI, kg/m2 (mean±SD) 26.06 ± 4.36 29.36 ± 5.63
Chronic disease, yes (n,%) 222, 52.11 275, 75.52
Medication intake, yes (n,%) 207, 48.59 265, 71.82
Severity of the last COVID19 (n,%)
Asymptomatic 38, 8.92 12, 3.25
Mild to moderate symptoms 368, 86.38 171, 46.34
Severe clinical picture 19, 4.46 186, 50.41
Number of COVID-19 infections (n,%)
1 285, 66.90 275, 74.52
2 or more 140, 33.10a 94, 25.48
Time—COVID-19 (n,%)
>3 months, and <6 months 51, 11.97 28, 7.58
>6 months, and <12 months 144, 33.80 45, 12.19
>12 months, and <24 months 190, 44.60 163, 44.17
>24 months 36, 8.45 133, 36.04
C19-YRS (median (IQR))
Symptom severity 6.0 (14.0) 17.0 (18.0)
Functional disability 0.0 (2.0) 2.0 (5.0)
Other symptoms 1.0 (3.0) 1.0 (4.0)
Overall health 7.0 (3.0) 6.0 (3.0)
Listed symptoms not counted in other symptoms subscale (n,%) 21, 4.92 119, 32.25
Fatigue severity scale (FSS) 3.0 (3.0) 5.0 (2.0)

SD, standard deviation; BMI, body mass index; IQR, inter quartile range; C19-YRS, COVID-19 Yorkshire Rehabilitation Scale; n, number; %, percentage.
‘Time-COVID-19’ refers to the last time subject got over COVID-19.
a
One subject did not provide answer on the number of COVID-19 infections.

Figure 2 presents the median values of C19-YRSm subscales for
the control and clinical groups, and Figure 3 shows the ‘Other
symptoms’ prevalence between the clinical and control groups.
In addition, it can be observed that the participants in the clin­
ical group listed significantly more symptoms that were not men­
tioned in the ‘Other symptoms’ subscale (v2¼101.40; P < 0.001).
Also, there was a significant difference in the number of Other
symptoms (Z ¼ 2.94; P < 0.01) between women and men, with
women having more symptoms. The most common symptoms in
women were weakness, movement problems, coordination prob­
lems in limbs and hair loss, while in men, the most common
symptoms were fever and weakness, movement problems or co­
ordination problems in limbs (Figure 4).
A significant difference was calculated for the FSS scale be­
tween the clinical and control groups (Z¼−9.98; P < 0.001), with
higher FSS scores in the clinical group (Table 1).
Convergent validity
A significant correlation was found across subscales ‘Symptom
severity’ subscale, ‘Functional disability’ and ‘Other symptoms’
(r ¼ 0.81; P<0.001; r ¼ 0.58; P<0.001; r ¼ 0.49; P<0.001), indicating
that C19-YRSm has a coherent internal structure. Moreover, the
‘Overall health’ subscale is negatively correlated with the follow­
ing subscales ‘Symptom severity’, ‘Functional disability’ and
‘Other symptoms’, respectively (r¼−0.58; P<0.001; r¼−0.49;
P<0.001; r¼−0.34; P<0.001).
FSS scale has weak to moderate correlations with the signifi­
cant P-values (Table 3) with ‘Symptom severity’ (r ¼ 0.62),
‘Functional disability’ (r ¼ 0.58) and ‘Other symptoms’ (r ¼ 0.40),
and a moderate negative correlation was found between FSS and
‘Overall health’ (r¼−0.49). Correlations of C19-YRSm subscales
with FSS indicate construct validity evidence. However, C19-
YRSm subscales have a weak correlation with other variables like
age, sex, BMI, the severity of COVID-19 and chronic disease.

Psychometric properties of the C19-YRS in
clinical group
Internal consistency
The ‘Symptom severity’ subscale (a ¼ 0.96), ‘Functional disability’
(a ¼ 0.89) and ‘Other symptoms’ (a ¼ 0.81) have high internal con­
sistency values, meaning C19-YRS subscales have excellent reli­
ability. Inter-item correlations (Table 2) indicate that all items on
each subscale correlate with the scale overall (rrange¼0.23–0.79).
Items in the ‘Other symptoms’ subscale with correlations under
0.2 (r < 0.2) are ‘Unintentional weight loss’ (r ¼ 0.16), ‘Skin rash/
discoloration of the skin’ (r ¼ 0.03) and ‘Thoughts about harming
yourself’ (r ¼ 0.11). It can be observed that these variables have
low or negligible correlations with the scale overall and thus may
be left out.
Concurrent validity
The C19-YRSm subscales (‘Symptom severity, Functional disabil­
ity’ and ‘Other symptoms’) mean values for the clinical group
were significantly higher (Mann–Whitney U test—Z value in
Table 1) than for control subjects. Furthermore, mean values for
C19-YRSm ‘Overall health’ in the clinical group were significantly
lower than for the control group.
Incremental validity
Table 4 represents the results of multiple hierarchical regression
analyses and the incremental validity of the C19-YRSm with
‘Overall health’ and FSS as criterion variables. For ‘Overall
health’, the first set of predictor variables (age, sex, BMI and
chronic disease), age, BMI and chronic disease had a significant b
coefficient accounting for 13% of the variance. Step 2, which
 L. Kustura et al. | 43

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Figure 2. Median values of C19-YRSm subscales for control and clinical group. Median values, interquartile range (25–75%) and min. to max. values of
scores on symptom severity (upper left view), functional disability (upper right view), other symptoms (lower left view) and overall health (lower right
view) subscales are presented for control and clinical group. On y-axis median values, interquartile range (25–75%) and min. to max. values of scores
on symptom severity, functional disability, other symptoms and overall health subscales are presented. On x-axis results for clinical and control group
are shown.

Figure 3. Prevalence of C19-YRSm other symptoms in control (N ¼ 426) and clinical (369) group.

included three C19-YRSm subscales (‘Symptom severity,
Functional disability, and Other symptoms’), shows that these
subscales explain an additional 22% of overall health variance.
Among these predictors, only ‘Symptom severity’ had significant
negative b, meaning greater symptom severity correlates to lower
overall health (Table 4), which agrees with achieved correlations
between subscales (Table 3).
For the FSS scale as a criterion variable, age, BMI and chronic
disease included in the first step had a significant b coefficient,
accounting for 11% of the variance. C19-YRSm subscales entered
in the second step explain an additional 31% of the FSS variance.
It can be seen that ‘Symptom severity’ and ‘Functional disability’
subscale variables significantly contribute to explaining the FSS
as a criterion variable.
Results indicate C19-YRSm subscales of the ‘Symptom sever­
ity’ variable contribute to explaining ‘Overall health’ variance
(incremental validity) concerning age, BMI and chronic disease
variables. Furthermore, C19-YRSm subscales of ‘Symptom
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Figure 4. Prevalence of C19-YRSm other symptoms in female (199) and male (N ¼ 170) subjects.

Table 2. Psychometric properties of the C19-YRSm subscales

Symptom severity (0–30) Functional disability (0–15) Other symptoms (0–25) Overall health (0–10)

Mean (SD) 19.31 (15.39) 3.35 (3.68) 2.41 (3.07) 5.50 (2.30)
Median (IQR) 17.0 (18.0) 2.0 (5.0) 1.0 (4.0) 6.0 (3.0)
Item mean-range 0.35–1.31 0.41–0.93 0.01–0.24
Item SD-range 0.67–0.99 0.76–0.98 0.09–0.43
Inter-item correlations 0.43–0.78 0.52–0.79 0.23–0.52
Cronbach’s a 0.96 0.89 0.81

Cronbach’s a (correlation coefficient)—measure of internal consistency. If equal or higher than 0.9, the internal consistency is excellent. If it is below 0.9 or equal or
higher than 0.8, the internal consistency is good.
SD, standard deviation; IQR, interquartile range.

Table 3. Correlations (significance) between C19-YRSm subscales and related variables

Symptom severity Functional symptoms Other symptoms Overall health

Symptom severity 0.81 (P<0.001) 0.58 (P<0.001) −0.55 (P<0.001)

Functional disability 0.49 (P<0.001) −0.49 (P<0.001)
Other symptoms −0.34 (P<0.001)
Overall health
FSS 0.62 (P< 0.001) 0.58 (P<0.001) 0.40 (P<0.001) −0.49 (P<0.001)
Severity of the last COVID19 0.22 (P < 0.001) 0.17 (P<0.01) 0.05 (P > 0.05) −0.21 (P<0.001)
Chronic disease (yes/no) 0.25 (P<0.001) 0.19 (P<0.001) 0.11 (P<0.05) −0.30 (P<0.001)
Age (years) 0.25 (P<0.001) 0.24 (P<0.001) 0.06 (P<0.001) −0.29 (P<0.001)
Sex (F/M) 0.06 (P > 0.05) 0.01(P > 0.05) 0.18 (P<0.05) −0.07 (P > 0.05)
BMI (kg/m2) 0.18 (P<0.001) 0.14 (P<0.05) −0.02 (P > 0.05) −0.23 (P<0.001)
The last time subject got over COVID-19 −0.11 (P<0.05) −0.17 (P<0.01) −0.14 (P < 0.05) −0.15 (P<0.05)

BMI, body mass index; F, female; M, male; FSS, fatigue severity scale.

Table 4. Multiple hierarchical regression analyses for the incremental validity of C19-YRSm

Overall health FSS

Step 1 b Step 2 b Step 1 b Step 2 b

Step 1 Age −0.16� −0.08 0.14� 0.04

Sex −0.03 −0.01 0.07 0.03
BMI −0.12� −0.08 0.12� 0.07
Chronic disease 0.19� 0.12� −0.19� −0.11�
R2 0.13 0.11
F (5363)¼11.08; P<0.001 F (5363)¼8.99; P<0.001
Step 2 Symptom severity −0.35� 0.36�
Functional disability −0.11 0.21�
Other symptoms −0.06 0.07
R2 0.35 0.42
F (8360)¼24.61; P < 0.001 F (8360)¼33.82; P < 0.001
DR2 0.22 0.31

B, standardized regression coefficient; R2, coefficient of determination; DR2, change in the coefficient of determination; � P < 0.05.

severity’ and ‘Functional disability’ explain FSS concerning age,
BMI and chronic disease.
Discussion
The C19-YRSm scale evaluates the severity of the symptoms,
functional disability and overall health in individuals with Long
Covid or post-COVID-19 syndrome. So far, the psychometric
properties of the C19-YRSm22 were not tested due to modifica­
tions and post hoc analysis on the original C19-YRS scale.26,27
Therefore, this study provides the psychometric results for the
C19-YRSm scale using reliability statistics (internal consistency)
and concurrent, convergent, incremental validity measures. The
reliability and validity testing were conducted on patients (clini­
cal group), while subjects from the general population (control
group) served to estimate the concurrent validity of C19-YRSm
subscales. Comparing the C19-YRSm scores between the clinical
and control group, the study confirmed the significantly higher
subscales mean values for the clinical group. This study showed
that C19-YRSm subscales (‘Symptom severity, Functional disabil­
ity, Other symptoms’) have excellent internal consistencies
(Cronbach’s a value 0.81–0.96) and acceptable inter-item correla­
tions (r value 0.23–0.79). According to study results, three items
from the C19-YRSm ‘Other symptoms’ subscale can be excluded
(‘unintentional weight loss, skin rash/discoloration of skin’ and
‘thoughts about harming yourself’). The convergent validity of
the C19-YRSm is good due to the significant correlations between
C19-YRSm subscales and between FSS. Furthermore, many previ­
ous studies evaluating COVID-19 symptomatology reported
fatigue as the common symptom in hospitalized and non-
hospitalized patients recovering from COVID-19.37–40 Also, the
FSS scale shows to be suitable for measuring fatigue in COVID-19
patients, confirmed by strong internal consistency (Cronbach’s a
of 0.96) and construct validity.37 In the study of Naik et al.,37 the
mean ± SD FSS score was 4.4 ± 1.8 in the hospitalized and 5.2 ± 1.6
in the non-hospitalized group, while in the presented study, the
FSS score was 5.0 ± 2.0 for the clinical group and 3.0 ± 3.0 for the
control group. Therefore, the FSS scores for the clinical group of
subjects are similar when comparing the results from Naik et
al.37 and the results of this study. This study findings on FSS in
the clinical group are also consistent with the cut-off score of �4
and �5 for clinically relevant fatigue.34–36 Moreover, chronic dis­
eases, the severity of COVID-19, higher BMI, older age and sex
were reported as significant predictors of Long Covid or post-
COVID-19 syndrome.40–45 Lastly, hierarchical regression analysis
showed consistent evidence for the incremental validity of the
C19-YRSm subscale (‘Symptom severity’) with C19-YRSm
‘Overall health’ subscale, and incremental validity of the C19-
YRSm subscale (‘Symptom severity, Functional disability’) with
FSS scale in association to age, BMI and chronic disease.
Furthermore, four studies46–49 have evaluated post-COVID
symptoms in subjects recovering from COVID-19 utilizing the
original version of the C19-YRS,26,27 with two studies reporting
valid results.46,49 Straudi et al.46 reported construct validity of
C19-YRS26 in a cohort of 79 hospitalized COVID-19 patients after
12- and 26-weeks post-infection showing C19-YRS moderate re­
sponsiveness of the most represented deficits, with Cronbach’s
alpha value (a ¼ 0.87) similar in Straudi et al.46 study with the
original C19-YRS version (a ¼ 0.891).27 Onwards, Partiprajak
et al.49 reported acceptable internal consistency and reliability of
C19-YRSm22 in 337 Thai community members in Bangkok,
Thailand. The Cronbach’s alpha value (a ¼ 0.723) in Partiprajak
et al.49 study was lower than that of the original C19-YRS version
L. Kustura et al. | 45
(a ¼ 0.891).27 Compared to previous studies46,49 that reported psy­
chometric characteristics for the original C19-YRS,27 this study
findings are the first to report an excellent internal consistency
(Cronbach’s a value 0.81–0.96) of C19-YRSm subscales.22
However, this study has the following limitations. Sivan et al.22
conducted Rasch analysis to test the psychometric properties of
the original version of the C19-YRS scale,26 while in this study,
Downloaded from https://academic.oup.com/qjmed/article/117/1/38/7288193 by UERJ - Universidade do Estado do Rio de Janeiro user on 11 March 2024
the classical psychometric analysis (reliability statistics, conver­
gent, concurrent and incremental validity measures) was applied
to test the psychometric properties of the C19-YRSm scale.50
Further, longitudinal monitoring of patients with post-COVID-19
symptomatology would be recommended utilizing the C19-YRSm
scale, which was also discussed by Sivan et al.22 Finally, the C19-
YRSm scale could be compared to recently published post-COVID
score calculated based on-self reported symptoms as reported by
Bahmer et al.51 Therefore, considering the limitations, future
studies might apply Rasch analysis to estimate the psychometric
properties of the C19-YRSm scale and to compare the results
with the classical psychometric analysis results for C19-YRSm,
as shown in this study.
To conclude, psychometric properties of prospectively col­
lected data were undertaken on the C19-YRSm scale showing
C19-YRSm to be a reliable and valid patient-reported outcome
measure that captures the common symptoms, functional dis­
ability and overall health in post-Covid-19.
Supplementary material
Supplementary material is available at QJMED online.
Acknowledgments
We wish to thank to all the participants and professionals in­
volved in providing care to individuals recovering from post-
COVID-19.
Author contributions
Lea Kustura (Conceptualization [lead], Data curation [lead],
Formal analysis [equal], Investigation [lead], Project administra­
tion [lead], Writing—review & editing [equal]), Nikolina Naranc � ic
�
Knez (Data curation [equal], Investigation [equal], Writing—re­
view & editing [equal]), Dubravka Bobek (Data curation [equal],
Investigation [equal], Writing—review & editing [equal]), Ana
�anin (Data curation [equal], Investigation [equal], Writing—
Poljic
review & editing [equal]), Sanda Pavelin (Data curation [equal],
Investigation [equal], Writing—review & editing [equal]), Maja
Buljuba�sic �
� Soda (Data curation [equal], Investigation [equal],
Writing—review & editing [equal]), Jo�sko Soda� (Data curation
[equal], Formal analysis [equal], Investigation [equal], Writing—
� (Data curation [equal],
review & editing [equal]), Jan Aksentijevic
Investigation [equal], Writing—review & editing [equal]), Klaudia
Duka Glavor (Data curation [equal], Investigation [equal],
Writing—review & editing [equal]), Vanja Viali (Data curation
[equal], Investigation [equal], Writing—review & editing [equal]),
Antonio Cukrov (Data curation [equal], Investigation [equal],
Writing—review & editing [equal]), Ivana Todoric � Laidlaw (Data
curation [equal], Investigation [equal], Writing—review & editing
[equal]), Nina Ipavec (Data curation [equal], Investigation [equal],
Writing—review & editing [equal]), Dora Vukorepa (Data curation
[equal], Investigation [equal], Writing—review & editing [equal]),
Ivona Stipica (Data curation [equal], Investigation [equal],
Writing—review & editing [equal]), Karla Bakrac � (Data curation
46 | QJM: An International Journal of Medicine, 2024, Vol. 117, No. 1
[equal], Investigation [equal], Writing—review & editing [equal]),
Braco Bo�skovic� (Supervision [equal], Writing—review & editing
[equal]), Angela Mastelic � (Data curation [equal], Investigation
[equal], Writing—review & editing [equal]), Nikolina Rez �
� ic
Muz � (Supervision [equal], Writing—review & editing [equal]),
�inic
Anita Markotic � (Supervision [equal], Writing—review & editing
[equal]), Zoran D- oga�s (Supervision [equal], Writing—review &
editing [equal]) and Kre�simir Dolic � (Supervision [equal],
Writing—review & editing [equal])
Conflict of interest
None declared.
Ethics statement
All procedures performed in studies involving human partici­
pants were in accordance with the ethical standards of the Ethics
Committee of the University of Split, School of Medicine, Croatia,
Class: 003-08/23-03/0015, No. 2181-198-03-04-23-0001 (approved
on January 2023) and the Ethics Committee of the University
Hospital of Split, Croatia, Class: 500-03/22-01/204, No. 2181-147/
01/06/M.S.-22-02 (approved on November 2022) and with the
1964 Helsinki Declaration and its later amendments or compara­
ble ethical standards. Before commencing the survey, partici­
pants were informed about the study details. Participation was
voluntary and anonymous.
Data availability
The dataset used and analysed during this study area available
from the corresponding author on reasonable request.
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