A psychometric evaluation of the Italian short version of the Fear of Pain Questionnaire-III: Psychometric properties, measurement invariance across gender, convergent, and discriminant validity

The study investigates the psychometric properties of a short Italian version of the Fear of Pain Questionnaire-III (FPQ-III), which assesses fear of pain across three domains: severe, medical, and minor pain. Building on fear-avoidance models of pain and prior cross-cultural work on the FPQ-III, the authors aim to validate a concise 13-item structure in an Italian adult sample, test measurement invariance across gender, and examine convergent validity with pain catastrophizing, locus of control, and coping styles. They also test discriminant validity using experimental manipulation via fear-eliciting videos to assess sensitivity to situational changes in fear of pain.

Prior research established the FPQ-III’s three-factor structure (severe, medical, minor pain) and supported short forms (FPQ-SF, FPQ-9). Cross-cultural validations exist in Spanish, French, Dutch, Portuguese, and Norwegian samples. Some studies reported limitations in the original structure and potential benefits of shorter versions. An earlier Italian validation (Di Tella et al., 2019) found acceptable fit for the 30-, 20-, and 9-item versions, with better fit for short forms, but had gender imbalance limitations. The literature also documents gender differences (higher fear in women) and the influence of cultural/linguistic factors. Related constructs and measures include pain catastrophizing (PCS), fear-avoidance beliefs (FABQ), and coping measures (COPE), which are theoretically linked to fear of pain and used here for convergent validity.

Design and translation: Following EORTC translation procedures, the FPQ-III was translated to Italian using forward-backward translation, reconciliation, and a focus group (n=10) across age, gender, and education, confirming item comprehensibility. Participants and samples: Recruitment targeted Italian university students. Of 3,400 invitations, 708 complete responses (333 males, 375 females; mean age 22.67, SD 2.47) were obtained for the primary psychometric analyses. A separate convenience sample (n=292; 113 males, 179 females; mean age 24.46, SD 7.39) was used for convergent validity. For discriminant validity, 64 participants (32 males; mean age 22.47) were randomized into four balanced groups (n=16 each) for a two-way repeated measures ANOVA (Group × Time) with pre-post assessments and a 24-hour interval. Measures: FPQ-III (30 items; 5-point Likert) assessing severe, medical, and minor pain fears; PCS (13 items; rumination, magnification, helplessness); LCBS (17 items; internal vs external locus of control); COPE-NVI (Italian version of COPE; multiple coping domains including avoidance, social support, positive attitude, problem orientation, transcendence). Discriminant validity manipulation: Three 50-second video compilations eliciting severe pain, medical pain, or minor pain were curated via a 24-student panel that rated relevance and emotional impact; overly disturbing content was excluded. Experimental groups viewed one of the videos; the control group had no video exposure between pre- and post-tests. Statistical analysis: Data screening addressed univariate/multivariate normality (standardization, Mahalanobis distance), collinearity (VIF, tolerance), and autocorrelation (Durbin–Watson). EFA used ML with Promax rotation on half the main sample; CFA on the other half (IBM Amos). Model fit indices: χ2, CFI, TLI, RMSEA (cutoffs: CFI/TLI > 0.95; RMSEA < 0.06). Measurement invariance across gender tested configural, metric, scalar, and strict invariance using ΔCFI/ΔTLI/ΔRMSEA ≤ 0.01 as criteria. Reliability assessed via Cronbach’s alpha and McDonald’s omega. Convergent validity used bootstrap correlations between FPQ-III factors and PCS, LCBS, COPE-NVI. Discriminant validity used two-way repeated measures ANOVA with Pillai’s criterion and partial eta squared; Bonferroni-corrected post hoc tests were conducted for significant interactions. Ethics: Institutional Review Board approval obtained; informed consent collected.

- Scale refinement and structure: The original 30-item three-factor model showed poor fit (e.g., CFI = 0.756; TLI = 0.736; RMSEA = 0.093). EFA led to iterative item removal, yielding a 13-item, three-factor solution (Severe Pain 4 items; Medical Pain 4 items; Minor Pain 5 items). CFA on the split sample (n=354) confirmed excellent fit: χ2 = 148.092; χ2/df = 2.51; CFI = 0.971; TLI = 0.962; RMSEA = 0.046 (90% CI 0.037–0.056). Factor intercorrelations were moderate (e.g., Severe–Medical r = 0.478; Severe–Minor r = 0.532; Medical–Minor r = 0.605; p < 0.01). - Reliability: Internal consistencies for the 13-item form were satisfactory (alphas/omegas approximately Severe 0.80, Medical 0.80, Minor 0.75). Across samples, ω/α ranged from ~0.70 to 0.89 depending on subscale. - Measurement invariance: Strict invariance across gender was supported. Latent mean comparisons (female reference) showed males had significantly lower fear across all factors: Severe Pain mean difference −0.98 (SE 0.13), Medical Pain −0.89 (SE 0.10), Minor Pain −0.82 (SE 0.11); all p < 0.001. - Descriptive/item properties: Ceiling effects were present for some items (e.g., item 13 ceiling 58.3%). Overall total score M = 35.71 (range 13–65), SD = 8.46. - Convergent validity (n=292): FPQ total correlated with PCS total r = 0.385**; with PCS Rumination r = 0.395**, Magnification r = 0.284**, Helplessness r = 0.315**. External locus of control correlated positively (r = 0.220**), while internal control correlated negatively (r = −0.123*). Coping correlations were small but in expected directions: avoidance r = 0.192**, social support r = 0.196**, transcendence r = 0.131*. - Discriminant validity (video experiment; n=64): Significant Group × Time interactions for all subscales: Severe Pain F(2.005,30.072) = 16.329, p < 0.005, ηp2 = 0.521; Medical Pain F(3,45) = 46.696, p < 0.001, ηp2 = 0.757; Minor Pain F(3,45) = 13.928, p < 0.001, ηp2 = 0.481. Post hoc results aligned with targeted manipulations: the severe-pain video increased Severe subscale scores in Group 1 vs minor-pain and control groups; the medical-pain video increased Medical subscale scores in Group 2 vs severe, minor, and control; unexpectedly, the minor-pain video led to a decrease in Minor subscale scores in Group 3 vs others. Means examples: Severe post-test Group 1 M=14.69±2.73 vs Group 3 M=12.12±2.16 and Group 4 M=11.62±1.41; Medical post-test Group 2 M=12.19±2.04 vs Group 1 M=9.06±3.07, Group 3 M=7.69±2.96, Group 4 M=8.94±1.91; Minor post-test Group 3 M=7.62±2.03 lower than Group 1 M=10.31±3.32, Group 2 M=10.25±1.98, Group 4 M=10.56±2.06 (Bonferroni-adjusted).

The findings support a concise 13-item Italian FPQ-III with a stable three-factor structure for severe, medical, and minor pain fears. Excellent CFA fit indices and satisfactory reliabilities indicate robust psychometric performance. Strict measurement invariance across gender confirms that comparisons of latent means are meaningful, and results show women report higher fear of pain across domains, in line with much of the literature. Convergent validity was supported by moderate positive associations with pain catastrophizing (particularly rumination) and small but significant relationships with external locus of control and avoidant/transcendent coping, aligning with fear-avoidance models. The experimental manipulation demonstrated discriminant validity and sensitivity to situational changes: domain-specific videos increased corresponding fear subscale scores; minor pain content unexpectedly decreased fear, potentially reflecting perceived controllability and self-efficacy for minor pain scenarios. Overall, the short Italian FPQ-III appears suitable both for dispositional assessment and for detecting state-related changes in fear of pain.

The Italian 13-item FPQ-III short form demonstrates good psychometric properties, including excellent three-factor model fit, satisfactory reliability, and strict measurement invariance across gender. Convergent validity with pain catastrophizing, locus of control, and coping styles is supported, and the scale is sensitive to experimentally induced changes in fear of pain. The short form enables efficient assessment of anticipatory fears of severe, medical, and minor pain, which may inform interventions and monitoring, given potential impacts on health behaviors (e.g., medical avoidance) and quality of life. Future research could examine longitudinal stability, clinical utility across patient populations, responsiveness to interventions, and further explore the mechanisms underlying the observed reduction in minor pain fear following exposure to minor-pain stimuli.