Exploratory Factor Analysis of the Vestibular Activities Avoidance Instrument

Pamela M. Dunlap, Gregory F. Marchetti, Patrick J. Sparto, Jeffrey P. Staab, Joseph M. Furman, Anthony Delitto, Susan L. Whitney

Research output: Contribution to journalArticlepeer-review


Importance: Fear avoidance is a behavioral response to dizziness that can lead to chronic symptoms and maladaptation of the vestibular system, but there is no valid and reliable clinical measure of fear avoidance for persons with dizziness. Although the Vestibular Activities Avoidance Instrument (VAAI) was developed to identify fear avoidance beliefs in persons with dizziness, it was considered too long for clinical use. Objective: To continue development of the VAAI for clinical use by reducing its length and by assessing the internal consistency and construct validity through associations with measures of disability, quality of life, and psychological well-being. Design, Setting, and Participants: This prospective cohort study conducted from February 2018 to December 2019 at a tertiary care balance disorders clinic and in outpatient physical therapy clinics in the United States included 404 adults with dizziness. Main Outcomes and Measures: Participants completed the 81-item VAAI, the Vestibular Activities and Participation (VAP) measure, the 12-Item Short Form Health Survey (SF-12), and the Hospital Anxiety and Depression Scale (HADS) at baseline. Exploratory factor analysis of the VAAI was conducted to reduce the number of items. Internal consistency of the reduced VAAI was determined by calculating the Cronbach a. Convergent validity was assessed by examining the associations between the reduced VAAI and the VAP, the SF-12, and the HADS using Spearman correlation coefficients. Results: Data from 404 adults (mean [SD] age, 54.0 [17.0] years; 64.6% women) were included in the analyses. The exploratory factor analysis indicated that 2 factors explained the underlying constructs of the 81-Item VAAI. The first factor was retained and measured the construct of fear avoidance. The VAAI was reduced to 9 items (VAAI-9). The VAAI-9 showed excellent internal consistency (Cronbach a = 0.92) and was positively associated with the VAP (? = 0.81) and the HADS anxiety (? = 0.47) and depression (? = 0.64) subscales, and negatively associated with physical (? = -0.76) and mental (? = -0.47) health-related quality of life. Conclusions and Relevance: These findings indicate that the VAAI-9 is a short, internally consistent, valid measure of fear avoidance and is associated with quality of life, activity limitations and participation restrictions, and psychological well-being. The next steps in the development of the VAAI-9 will include validation in an external sample, assessment of test-retest validity, and prospective investigations of its association with future disability..

Original languageEnglish (US)
Pages (from-to)144-150
Number of pages7
JournalJAMA Otolaryngology - Head and Neck Surgery
Issue number2
StatePublished - Feb 2021

ASJC Scopus subject areas

  • Surgery
  • Otorhinolaryngology


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