In e na ional Jou nal o
En i onmen al Resea ch
and Public Heal h
A icle
Psychome ic P ope ies o he Spanish Ve sion o he
Ca egi e Bu den In en o y
Fe nando L. Vázquez 1,* , Pa icia O e o 2, Miguel A. Simón2, Ana M. Bueno 2and
Vanessa Blanco 3
1Depa men o Clinical Psychology and Psychobiology, Uni e si y o San iago de Compos ela,
15782 San iago de Compos ela, Spain
2Depa men o Psychology, Uni e si y o A Co uña, 15701 A Co uña, Spain;
pa icia.o e o.o e [email p o ec ed] (P.O.); [email p o ec ed] (M.A.S.); [email p o ec ed] (A.M.B.)
3Depa men o E olu iona y and Educa ional Psychology, Uni e si y o San iago de Compos ela,
15782 San iago de Compos ela, Spain; [email p o ec ed]
*Co espondence: [email p o ec ed]; Tel.: +34-881-813-705
Recei ed: 7 Decembe 2018; Accep ed: 11 Janua y 2019; Published: 14 Janua y 2019

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Abs ac :
Al hough he Ca egi e Bu den In en o y (CBI) is he mos widely used mul idimensional
bu den ins umen o assessing pe cei ed bu den o ca egi e s, he e is no da a on i s psychome ic
p ope ies in Spanish, no on ca egi e s o dependen pe sons wi h a ious diseases. The objec i e o
his s udy was o ansla e he CBI in o Spanish and alida e i in ca egi e s o dependen pe sons
wi h a ious diseases. T ained e alua o s adminis e ed he CBI and assessed emo ional dis ess
and p obable men al diso de in 201 ca egi e s (87.1% women, mean age 56.2 yea s). The in e nal
consis ency o he CBI was 0.89 (0.74–0.83 among he subscales). The e was a signi ican co ela ion o
emo ional dis ess wi h bo h he o al bu den and each subscale (p< 0.001 in all cases). A o al sco e o
39 and sco es o 16, 9, 8, 4, and 2 in bu den pe ime dedica ed o ca e, pe sonal li e bu den, physical
bu den, social bu den, and emo ional bu den we e sui able cu -o poin s o disc imina e ca egi e s
wi h p obable men al diso de (sensi i i y = 63.0%–75.6%, speci ici y = 63.4%–74.4%). To achie e a
g ea e goodness o i , he model was e-speci ied, esul ing in a sho ened (15-i em) ins umen .
The in e nal consis ency eliabili y coe icien s o he 15-i em CBI we e sa is ac o y (C onbach
α
=
0.83; 0.77–0.86 among he subscales). Wi hin he 15-i em CBI, emo ional dis ess was signi ican ly
co ela ed wi h he o al bu den, pe sonal li e bu den, physical bu den, social bu den (p< 0.001 in
all hose cases), and emo ional bu den (p= 0.001). A o al sco e o 25 and sco es o 12, 5, 5, 3, and 1,
espec i ely, in he subscales we e iden i ied as cu -o poin s o disc imina e ca egi e s wi h p obable
men al diso de (sensi i i y = 46.2%–70.6%, speci ici y = 43.9%–79.3%). The e o e, he 15-i em CBI
alidly measu ed ca egi e bu den wi h be e i and mo e pa simoniously han he o iginal CBI.
Keywo ds:
Ca egi e Bu den In en o y; psychome ic p ope ies; in e nal consis ency; ac o
analysis; bu den; ca egi e s; Spanish
1. In oduc ion
Dependency has demons a ed apid g ow h in ecen yea s [
1
]. Al hough he a ailabili y o ca e
and se ices o may di e signi ican ly ac oss coun ies [
2
], in he coun ies o he O ganiza ion
o Economic Coope a ion and De elopmen mo e han one in 10 adul s assumes he ole o
non-p o essional ca egi e [3].
Ne e heless, ca ing o a dependen lo ed one usually ex ends o e ime and equi es long hou s
o daily dedica ion (e.g., [
4
,
5
]), which can nega i ely impac he li es o ca egi e s. Mos si ua ions
o ca e esul in a dec ease o ee ime and a de e io a ion o amily ela ionships (80.2% o cases),
In . J. En i on. Res. Public Heal h 2019,16, 217; doi:10.3390/ije ph16020217 www.mdpi.com/jou nal/ije ph
In . J. En i on. Res. Public Heal h 2019,16, 217 2 o 19
damage o wo king li e and inancial s abili y (61.1% o cases), and a wo sening o pe cei ed heal h
(55.6% o cases) [
6
]. In addi ion, o en he social suppo ha ca egi e s ecei e by people a ound hem
is limi ed [
7
]. Thus, ca ing o someone else becomes a sou ce o s ess ha can nega i ely impac he
ca egi e and gene a e consequences de ined as bu den o he ca egi e .
The concep ualiza ion o ca egi e bu den has e ol ed o e ime. Ini ially i was de ined as “any
cos o he amily” [
8
], whe e i was conside ed a global and one-dimensional cons uc . Then i was
unde s ood as a wo-dimensional concep ha encompasses he objec i e bu den (i.e., ac i i ies
and demands o ca e) and he subjec i e bu den (i.e., a i udes and emo ional eac ion o he
ca egi e ) [
9
]. Now ca egi e bu den is unde s ood as a mul idimensional cons uc ha includes
physical, psychological, emo ional, social, and economic consequences [
10
–
12
]. This concep ualiza ion
o bu den is in line wi h he s ess model adap ed o he ca egi e popula ion, which includes s esso s
di ec ly and indi ec ly ela ed o ca e [13].
Ca egi e s expe iencing high bu den a e a g ea e isk o expe iencing psychological dis ess [
14
],
anxie y and dep ession [
15
,
16
] and epo lowe quali y o li e [
17
]. As a esul , he quali y o ca e
hey p o ide may be diminished, and in some cases, negligence and mis ea men o he dependen
indi idual ha e been epo ed [18].
The e o e, he e alua ion and de ec ion o he bu den is c ucial. Among he cu en ly a ailable
bu den assessmen ins umen s, he Ca egi e Bu den In en o y (CBI) [
19
] is he mos widely
used in he scien i ic li e a u e ha is consis en wi h he cu en concep o bu den. The CBI is
a mul idimensional measu e ha e alua es di e en mani es a ions o ca egi e bu den, allowing
he iden i ica ion o he speci ic needs o each ca egi e [
20
–
22
]. Fo i s cons uc ion, 16 i ems we e
gene a ed based on he expe iences o 64 ca egi e s; subsequen ly, 8 i ems we e added, selec ed om
he e iew o he scien i ic li e a u e. The inal ques ionnai e consis s o 24 i ems whose psychome ic
p ope ies we e analyzed in a sample o 171 ca egi e s o people wi h Alzheime ’s disease o cogni i e
impai men . The o iginal English e sion has i e ac o s: ime dependence bu den, de elopmen al bu den,
physical bu den, social bu den, and emo ional bu den, whose in e nal consis encies we e 0.85, 0.85, 0.86,
0.73, and 0.77, espec i ely.
The o iginal English e sion o he CBI has subsequen ly been alida ed in I alian [
16
] and
Chinese [
23
] wi h ca egi e s o elde ly people wi h demen ia, and in Po uguese wi h ca egi e s
o elde ly people [
24
]. Howe e , despi e he la ge numbe o non-p o essional ca egi e s in Spain
(and o he Spanish-speaking coun ies) [
1
,
25
] i has no been alida ed in Spanish, and i is unknown
whe he he o iginal s uc u e o he CBI i s o he da a o Spanish samples and o ca egi e s o
dependen pe sons wi h a ious diseases. In addi ion, al hough i s subscales a e posi i ely co ela ed
wi h anxie y and dep ession [
15
,
16
], i is unknown whe he he e is an adequa e cu -o poin o
disc imina e p obable cases o men al diso de . The objec i e o his s udy was o ansla e he CBI
in o Spanish and alida e i using con i ma o y ac o analysis, analyzing i s psychome ic p ope ies
in non-p o essional ca egi e s o dependen pe sons wi h a ious diseases.
2. Ma e ials and Me hods
2.1. Sample
A c oss-sec ional s udy was conduc ed. The sample was selec ed by simple andom sampling
om he o icial egis e o ca egi e s o he Minis y o Labo and Wel a e o he Xun a de Galicia
(Spain), a egion o 29,434 km
2
in no hwes Spain wi h 2,732,347 inhabi an s. Fo his, we signed an
ag eemen wi h his ins i u ion o acili a e con ac wi h ca egi e s and we ollowed he coming s eps:
(1) Make a lis o all he non-p o essional ca egi e s (n= 18,410); (2) Assign a sequen ial numbe o
each subjec (1, 2, 3,
. . .
, 18,410); (3) Figu e ou he sample size (n= 210); (4) Use a andom numbe
gene a o o selec he sample, using ou sampling ame om S ep 2 and ou sample size om S ep 3
(i.e., 210 andom numbe s be ween 1 and 18,410 we e gene a ed).
In . J. En i on. Res. Public Heal h 2019,16, 217 3 o 19
To pa icipa e in his s udy, he pa icipan s had o: (a) be a amily ca egi e o a pe son whose
dependence was o icially ecognized, (b) li e wi h he pe son ca ed o , and (c) p o ide in o med
consen . Exclusion c i e ia included: (a) p esen ing wi h any di icul y in communica ion (e.g., no
being able o ead o w i e) o any condi ion ha could in e e e wi h pa icipa ion in he s udy
(e.g., signi ican cogni i e impai men , se e e isual impai men ), o (b) ha ing ecei ed psychological
o pha macological ea men in he las wo mon hs.
The esponse a e was 95.7%. O he 210 ca egi e s con ac ed o pa icipa e in he s udy, 9 e used
pa icipa ion, esul ing in a inal sample o 201 ca egi e s. O he 201 pa icipan s, 87.1% we e women
wi h a mean age o 56.2 yea s (SD = 10.1), 79.6% had a pa ne , 64.2% had a ended elemen a y school,
55.7% had a mon hly amily income be ween 1000 and 1999 eu os and 43.8% ook ca e o hei a he
o mo he . O he people ca ed o , 55.7% we e women wi h an a e age age o 71.6 yea s (SD = 21.5),
and 54.2% had a physical disabili y. On a e age, he pa icipan s had been ca ing o hei amily
membe o 14.5 yea s (SD = 11.7) and 16.2 h pe day (SD = 5.3). The a e age sco e o emo ional
dis ess was 4.1 (SD = 3.2), wi h 59.2% p esen ing a p obable case o men al diso de (Table 1).
Table 1. Sociodemog aphic, ca e and clinical cha ac e is ics.
Va iables n= 201 %
Gende
Male 26 12.9
Female 175 87.1
Age
M (SD) 56.2 (10.1)
Ma i al s a us
Single 41 20.4
Pa ne ed 160 79.6
Educa ional le el
Li e a e 30 14.9
Elemen a y school 129 64.2
High school–college 42 20.9
Mon hly income
<999 eu os 71 35.3
Be ween 1000 and 1999 eu os 112 55.7
>2000 eu os 18 9.0
Rela ionship wi h he dependen
Pa en 88 43.8
Spouse 20 10.0
Daugh e /son 42 20.9
O he ela i es 45 22.4
No ela ed 6 3.0
Dependen gende
Male 89 44.3
Female 112 55.7
Dependen age
M (SD) 71.6 (21.5)
Disease o he dependen
In ellec ual disabili y 19 9.5
Men al diso de 16 8.0
Physical disabili y 110 54.7
Cogni i e impai men 56 27.9
Time dedica ed o ca e (yea s)
M (SD) 14.5 (11.7)
Daily hou s dedica ed o ca e
M (SD) 16.2 (5.3)
Emo ional dis ess
M (SD) 4.1 (3.2)
P obable case o men al diso de
Yes 119 59.2
No 82 40.8
In . J. En i on. Res. Public Heal h 2019,16, 217 4 o 19
The s udy was conduc ed in acco dance wi h he Decla a ion o Helsinki, and he p o ocol was
app o ed by he Bioe hics Commi ee o he Uni e si y o San iago de Compos ela (Code numbe
07092016). All subjec s ga e hei in o med consen o inclusion be o e hey pa icipa ed in he s udy.
Pa icipa ion was olun a y, wi hou economic compensa ion o any incen i e.
2.2. Ins umen s
The cha ac e is ics o he pa icipan s we e e alua ed ia an ad hoc ques ionnai e including
sociodemog aphic a iables (gende , age, ma i al s a us, educa ional le el, and mon hly income) and
ca e si ua ion cha ac e is ics ( ela ionship wi h he dependen , dependen gende , dependen age,
disease o he dependen , ime dedica ed o ca e, and daily hou s dedica ed o ca e). Ca egi e bu den
was assessed by he CBI [
19
], wi h an in e nal consis ency o each subscale in he o iginal e sion
o 0.85, 0.85, 0.86, 0.73, 0.77. Emo ional dis ess was assessed wi h he Gene al Heal h Ques ionnai e
(GHQ-12) [
26
], Spanish e sion o Rocha, Pé ez, Rod íguez-Sanz, e al. [
27
], whose in e nal consis ency
o he Spanish e sion is 0.86 o people unde 65 and 0.90 o people 65 and olde . A cu -o poin o
2/3 disc imina es possible cases o men al diso de [28].
2.3. P ocedu e
The aim o linguis ic alida ion is o ob ain ansla ions ha a e concep ually equi alen o he
o iginal, compa able ac oss languages, and easily unde s ood by he people o whom he ansla ed
ins umen is adminis e ed [
29
]. To adap he o iginal English CBI e sion o Spanish ca egi e s, i was
ansla ed ollowing he ecommenda ions o Guillemin, Bomba die and Bea on [
30
], Hamble on
and Zenisky [
31
] and he In e na ional Tes Commission [
32
], including o wa d and backwa d
ansla ion [
33
]. We used independen o wa d and backwa ds ansla o s who we e expe ienced in
ansla ing psychological ins umen s and na i e speake s o he a ge languages. The English e sion
was i s ansla ed in o Spanish (including ins uc ions, i ems and esponse op ions) by ou Spanish
na i e-speake esea che s. This d a o he Spanish e sion was hen back- ansla ed by an English
na i e-speake ansla o who had no p e ious exposu e o he o iginal English e sion o he CBI.
Disc epancies be ween he meaning o he ansla ion and ha o he o iginal e sion we e e iewed
and discussed by he ansla o s un il consensus was eached. Then, a commi ee o expe s wi hin he
domains o clinical and de elopmen al psychology wi h expe ise in he ca egi e popula ion judged
he ansla ion. The ansla ion-back ansla ion p ocess was epea ed and he commi ee discussed
wi h he ansla o s un il a new consensus was ob ained on he seman ic, idioma ic, expe ien ial and
concep ual equi alence be ween he Spanish e sion and he o iginal English e sion. This p e- inal
e sion was p esen ed o 10 ca egi e s ha we e no included in he s udy, o ensu e he unde s anding
o he ques ionnai e. No addi ional modi ica ions we e necessa y, and his inal e sion was used in
he s udy.
Ca egi e s we e con ac ed h ough le e s and phone calls. The cha ac e is ics o he s udy
we e explained o hem and hey we e in i ed o pa icipa e. To minimize d opou s, we ollowed
he da a collec ion s a egies o c oss-sec ional s udies [
34
], such as making he p esen a ion o
he s udy a ac i e o pa icipan s, ea ing he pa icipan s wi h kindness, a ec ion and espec ,
and a oiding collec ing in o ma ion in an in asi e way. In o ma ion abou he cha ac e is ics o he
pa icipan s, he si ua ion o ca e, ca egi e bu den and emo ional dis ess was collec ed ia sel - epo
in public cen e s close o he ca egi e s’ homes by h ee psychologis s, who we e p e iously ained.
The e alua ion was comple ed in app oxima ely 40 min.
2.4. Da a Analysis
To analyze he di e ences in he o al bu den sco e and i s subscales as a unc ion o he
sociodemog aphic cha ac e is ics and he ca e si ua ion, S uden ’s - es s, analysis o a iance (ANOVA)
o Pea son’s co ela ions we e used.
In . J. En i on. Res. Public Heal h 2019,16, 217 5 o 19
To analyze he in e nal consis ency o he CBI, we calcula ed he C onbach
α
coe icien .
We calcula ed he Pea son co ela ions be ween he i ems and be ween he sco e o each i em and he
o al co ec ed sco e (i.e., he o al sco e wi hou conside ing said i em).
We applied he maximum likelihood me hod o pe o m a con i ma o y ac o analysis o e i y
he ac o ial s uc u e o he ques ionnai e. The goodness o i be ween he model and he obse ed
da a was e i ied by he ollowing indices: (a) a signi ican
χ2M
(gene alized likelihood a io), (b) Roo
Mean Squa e E o o App oxima ion (RMSEA) alues
≤
0.06, (c) Goodness o Fi Index (GFI) >
0.90, (d) Adjus ed Goodness-o - i Index (AGFI) > 0.90, (e) Compa a i e Fi Index (CFI) close o 0.95,
( ) No malized Fi Index (NFI) close o 0.95, (g) lowe alues o Expec ed C oss Valida ion Index
(ECVI) [
35
,
36
]. In addi ion, he s anda dized ac o loadings o each i em on i s espec i e ac o is
equi ed o be ≥0.50 [37].
To examine he c i e ion alidi y o he CBI, we used he Pea son co ela ion o he CBI wi h
emo ional dis ess, he S uden - es o independen samples and a disc iminan classi ica ion
analysis wi h he p obable cases o men al diso de . A Recei e ’s Ope a ing Cha ac e is ics (ROC)
cu e analysis was pe o med o de e mine he op imal disc imina i e cu -o poin o de e mining
p obable cases o men al diso de . The indices o sensi i i y, speci ici y, posi i e p edic i e alue (PPV),
and nega i e p edic i e alue (NPV) we e calcula ed.
To achie e a g ea e goodness o i , he model was e-speci ied and he analyses we e epea ed.
Speci ically, hose i ems ha con ibu ed less o hei co esponding ac o we e elimina ed and
he h ee i ems wi h he highes ac o loading o each ac o we e selec ed [
37
–
39
]. Subsequen ly,
he same analyses we e epea ed wi h he sho ened e sion o he ins umen as hose ha had been
conduc ed wi h he o iginal CBI. The analyses we e pe o med wi h he s a is ical package SPSS o
Windows ( e sion 20.0, IBMCo p., A monk, NY, USA) and SPSS_Amos G aphics ( e sion 25, IBM
Co p., Mead ille, PA, USA).
3. Resul s
3.1. O iginal CBI
3.1.1. Bu den and Sample Cha ac e is ics
The e was signi ican a ia ion in he o al ca egi e bu den depending on he illness o he pe son
ca ed o , F(3, 196) = 7.194, p< 0.001, wi h signi ican ly lowe bu den on ca egi e s o people wi h
physical disabili ies compa ed o hose o people wi h cogni i e impai men (p< 0.001). The o al
bu den sco e co ela ed posi i ely and signi ican ly wi h he age o he pe son ca ed o ( = 0.152,
p= 0.032) and he daily hou s o ca e ( = 0.171, p= 0.015).
When analyzing he subscales, he e we e signi ican di e ences in bu den pe ime dedica ed o
ca e depending on he illness o he pe son ca ed o , F(3, 196) = 13.53, p< 0.001, wi h signi ican ly
lowe bu den in he ca egi e s o people wi h physical disabili ies compa ed o hose o people wi h
in ellec ual disabili ies (p= 0.008), men al diso de s (p= 0.011), and cogni i e impai men (p< 0.001).
The bu den pe ime dedica ed o ca e co ela ed posi i ely and signi ican ly wi h he daily ca e hou s
( = 0.261, p< 0.001).
The e we e also di e ences in pe sonal li e bu den depending on he illness o he pe son being
ca ed o , F(3, 196) = 5.68, p= 0.001, wi h signi ican ly highe bu den on he ca egi e s o people
wi h cogni i e impai men han on hose o people wi h in ellec ual (p= 0.026) o physical (p= 0.002)
disabili ies. The pe sonal li e bu den co ela ed posi i ely and signi ican ly wi h he age o he pe son
ca ed o ( = 0.226, p= 0.001), and he daily hou s o ca e ( = 0.153, p= 0.030).
Physical bu den di e ed depending on he illness o he pe son ca ed o , F(3, 196) = 5.38, p= 0.001,
being signi ican ly lowe in ca egi e s o people wi h physical disabili ies han in hose wi h men al
diso de s (p= 0.041) and cogni i e impai men s (p= 0.005). Finally, single ca egi e s had a highe
social bu den han pa ne ed ca egi e s (199) = 3.06, p= 0.003.

In . J. En i on. Res. Public Heal h 2019,16, 217 6 o 19
3.1.2. Reliabili y Analysis
The mean CBI sco e was 42.0 (SD = 15.9, ange 6–93). The a e age sco es o each subscale we e:
16.1 (SD = 3.3) on bu den pe ime dedica ed o ca e, 9.0 (SD = 5.2) on pe sonal li e bu den, 9.5 (SD =
5.4) on physical bu den, 5.2 (SD = 4.5) social bu den, and 2.2 (SD = 3.0) on emo ional bu den. Among
he esponses o he ca egi e s, 36.4% o he i ems we e sco ed as 0; 12.6% sco ed as 1; 18.4% sco ed as
2; 13.1% sco ed as 3 and 19.5% sco ed as 4. The mean o he i ems anged om 0.14 o i em 21 o 3.68
o i em 2 (Table 2). The co ec ed i em- o al co ela ion coe icien s we e all signi ican (p< 0.001) and
spanned om 0.15 o i em 4 o 0.76 o i em 9. The mean o he in e -i em co ela ion coe icien was
0.253, wi h a minimum o −0.13 and a maximum o 0.79.
The o al CBI showed an in e nal consis ency o 0.89. The C onbach’s
α
was 0.74 in bu den pe
ime dedica ed o ca e, 0.83 in pe sonal li e bu den, 0.78 in physical bu den, 0.75 in social bu den,
and 0.78 in emo ional bu den.
3.1.3. Analysis o Validi y
(1) Fac o ial s uc u e
In he con i ma o y ac o analysis, he adjus men indices we e he ollowing:
χ2M (242)
= 704.07;
p< 0.001, RMSEA = 0.098 (95% CI 0.089–0.106), GFI = 0.766, AGFI = 0.710, CFI = 0.789, NFI = 0.714 and
ECVI = 4.100. Figu e 1shows he s anda dized loads and he co a iances be ween ac o s. The i ems
had signi ican ac o ial loads, anging be ween 0.31 in i em 5 and 0.90 in i em 1. The co a iances we e
signi ican be ween pe sonal li e and physical bu den, pe sonal li e and social bu den, physical and
social bu den.
In . J. En i on. Res. Public Heal h 2019, 16, x FOR PEER REVIEW 7 o 17
24. Me en adan mis in e acciones con la pe sona a la que cuido
(I eel ang y abou my in e ac ions wi h my ca e ecei e ) 0.98 1.07 45.7 20.4 27.4 3.5 3.0 0.45
To al C onbach’s α 0.89
Bu den pe ime dedica ed o ca e—C onbach’s α 0.74
Pe sonal li e bu den—C onbach’s α 0.83
Physical bu den—C onbach’s α 0.78
Social bu den—C onbach’s α 0.75
Emo ional bu den—C onbach’s α 0.78
Mean in e -i em co ela ion coe icien 0.253
The o al CBI showed an in e nal consis ency o 0.89. The C onbach’s α was 0.74 in bu den pe
ime dedica ed o ca e, 0.83 in pe sonal li e bu den, 0.78 in physical bu den, 0.75 in social bu den,
and 0.78 in emo ional bu den.
3.1.3. Analysis o Validi y
(1) Fac o ial s uc u e
In he con i ma o y ac o analysis, he adjus men indices we e he ollowing: χ2M (242) = 704.07;
p < 0.001, RMSEA = 0.098 (95% CI 0.089–0.106), GFI = 0.766, AGFI = 0.710, CFI = 0.789, NFI = 0.714 and
ECVI = 4.100. Figu e 1 shows he s anda dized loads and he co a iances be ween ac o s. The i ems
had signi ican ac o ial loads, anging be ween 0.31 in i em 5 and 0.90 in i em 1. The co a iances
we e signi ican be ween pe sonal li e and physical bu den, pe sonal li e and social bu den, physical
and social bu den.
Figu e 1. Resul s o he con i ma o y ac o ial analysis o he o iginal ca egi e bu den in en o y (CBI).
(2) Rela ionship be ween he o iginal CBI and GHQ-12
The le el o emo ional dis ess was signi ican ly posi i ely co ela ed wi h he o al bu den sco e
( = 0.636, p < 0.001). In addi ion, ca egi e s wi h p obable men al diso de p esen ed highe bu den
sco es han hose wi hou p obable men al diso de , (196) = −9.165, p < 0.001.
Using a disc iminan classi ica ion analysis in he o al CBI, Wilks’ lambda was 0.72, χ2(1, n =
201) = 64.80, p < 0.001. The canonical co ela ion, which measu es associa ion be ween disc iminan
Figu e 1. Resul s o he con i ma o y ac o ial analysis o he o iginal ca egi e bu den in en o y (CBI).
In . J. En i on. Res. Public Heal h 2019,16, 217 7 o 19
Table 2. Means, s anda d de ia ions, sco e equency and co ec ed i em- o al co ela ion ( o ) o each i em o he o iginal Ca egi e Bu den In en o y (CBI).
I ems MSD Sco e F equency (%) o
01234
Ca ga po iempo de dedicación (Time-dependence bu den)
1. La pe sona que cuido necesi a mi ayuda pa a lle a a cabo muchas a eas
dia ias (My ca e ecei e needs my help o pe o m many daily asks) 3.66 0.66 0.5 1.0 4.5 20.4 73.6 0.18
2. La pe sona que cuido depende de mi (My ca e ecei e is dependen on me) 3.68 0.60 0.0 0.5 5.5 19.4 74.6 0.29
3. Tengo que igila cons an emen e a la pe sona que cuido (I ha e o wa ch my
ca e ecei e cons an ly) 2.81 1.28 9.0 6.5 20.4 23.4 40.7 0.46
4. Tengo que ayuda a la pe sona que cuido en muchas ac i idades básicas (I
ha e o help my ca e ecei e wi h many basic unc ions) 3.64 0.72 1.0 1.0 5.5 18.4 74.1 0.15
5. No engo ni un minu o de descanso de mis labo es de cuidado (I do no ha e a
minu e’s b eak om my ca egi ing cho es) 2.31 1.21 10.0 12.4 33.8 23.9 19.9 0.47
Ca ga en la ida pe sonal (De elopmen al bu den)
6. Sien o que es oy despe diciando mi ida (I eel ha I am missing ou on li e) 1.41 1.31 35.3 18.4 25.4 12.4 8.5 0.56
7. Desea ía pode escapa de es a si uación (I wish I could escape om
his si ua ion) 1.34 1.24 35.8 17.9 29.4 10.4 6.5 0.63
8. Mi ida social se ha de e io ado (My social li e has su e ed) 2.10 1.45 22.9 9.0 25.8 19.4 22.9 0.57
9. Me sien o emocionalmen e ago ado debido a la a ención dedicada a la pe sona
que cuido (I eel emo ionally d ained due o ca ing o my ca e ecei e ) 1.88 1.28 19.9 15.9 34.4 16.9 12.9 0.76
10. Espe aba que las cosas ue an di e en es en es e momen o de mi ida (I
expec ed ha hings would be di e en a his poin in my li e) 2.26 1.45 20.9 6.5 24.4 22.9 25.3 0.44
Ca ga ísica (Physical bu den)
11. No consigo do mi lo su icien e (I am no ge ing enough sleep) 2.10 1.45 23.4 8.0 25.8 20.9 21.9 0.47
12. Mi salud se ha de e io ado (My heal h has su e ed) 1.84 1.39 25.4 15.9 23.4 20.9 14.4 0.62
13. Se cuidado me ha hecho en e ma ísicamen e (Ca egi ing has made me
physically sick) 1.47 1.38 36.3 17.9 17.4 19.4 9.0 0.67
14 Es oy cansado ísicamen e (I am physically i ed) 2.18 1.28 14.4 11.4 35.9 18.9 19.4 0.60
In . J. En i on. Res. Public Heal h 2019,16, 217 8 o 19
Table 2. Con .
I ems MSD Sco e F equency (%) o
01234
Ca ga social (Social bu den)
15. No me lle o an bien como an es con o os miemb os de mi amilia (I do no
ge along wi h o he amily membe s as well as I used o) 0.97 1.31 53.7 19.4 12.4 5.0 9.5 0.50
16. Mis es ue zos como cuidado no son ap eciados po o os miemb os de mi
amilia (My ca egi ing e o s a e no app ecia ed by o he s in my amily) 1.32 1.40 41.3 18.9 17.9 10.0 11.9 0.44
17. He enido p oblemas en mi ma imonio (I ha e had p oblems wi h
my ma iage) 0.76 1.12 60.2 17.4 11.4 8.0 3.0 0.49
18. No hago an bien mis a eas en el abajo como solía hace lo (I do no do as
good a job a wo k as I used o) 1.09 1.13 41.2 22.9 23.9 9.0 3.0 0.52
19. Me sien o esen ido con o os amilia es que pod ían ayuda pe o no lo hacen
(I eel esen ul o o he ela i es who could bu do no help) 1.03 1.34 52.2 18.9 11.9 7.5 9.5 0.48
Ca ga emocional (Emo ional bu den)
20. Me a e güenza el compo amien o de la pe sona que cuido (I eel
emba assed o e my ca e ecei e ’s beha io ) 0.31 0.72 80.1 12.4 5.0 1.5 1.0 0.41
21. Me sien o a e gonzado de la pe sona que cuido (I eel ashamed o my
ca e ecei e ) 0.14 0.55 92.0 5.0 1.5 0.5 1.0 0.33
22. Es oy esen ido con la pe sona que cuido (I esen my ca e ecei e ) 0.32 0.74 80.6 10.9 6.0 1.5 1.0 0.43
23. Me sien o incómodo cuando engo amigos de isi a (I eel uncom o able
when I ha e iends o e ) 0.49 0.88 71.2 13.9 11.4 2.0 1.5 0.48
24. Me en adan mis in e acciones con la pe sona a la que cuido (I eel ang y
abou my in e ac ions wi h my ca e ecei e ) 0.98 1.07 45.7 20.4 27.4 3.5 3.0 0.45
To al C onbach’s α0.89
Bu den pe ime dedica ed o ca e—C onbach’s α0.74
Pe sonal li e bu den—C onbach’s α0.83
Physical bu den—C onbach’s α0.78
Social bu den—C onbach’s α0.75
Emo ional bu den—C onbach’s α0.78
Mean in e -i em co ela ion coe icien 0.253
In . J. En i on. Res. Public Heal h 2019,16, 217 9 o 19
(2) Rela ionship be ween he o iginal CBI and GHQ-12
The le el o emo ional dis ess was signi ican ly posi i ely co ela ed wi h he o al bu den sco e
( = 0.636, p< 0.001). In addi ion, ca egi e s wi h p obable men al diso de p esen ed highe bu den
sco es han hose wi hou p obable men al diso de , (196) = −9.165, p< 0.001.
Using a disc iminan classi ica ion analysis in he o al CBI, Wilks’ lambda was 0.72,
χ2
(1, n=
201) = 64.80, p< 0.001. The canonical co ela ion, which measu es associa ion be ween disc iminan
sco es and g oup membe ship, was 0.53. This analysis co ec ly classi ied 72.6% o he cases (Table 3).
The a ea unde he ROC cu e was 0.81 (95% CI 0.75–0.87; Figu e 2). Fo he cu -o poin o 39, he es
showed a sensi i i y o 75.6%, speci ici y o 74.4%, PPV o 81.1%, and NPV o 67.8% (Table 4).
Table 3. Disc iminan analysis and pe cen age o cases co ec ly classi ied o he o iginal CBI.
To al/Subscales Wilks’
Lambda (χ2)
Canonical
Co ela ion
P obable Cases o
Men al Diso de
No Cases o
Men al Diso de To al
To al bu den 0.72 (64.80) ** 0.53 69.7 76.8 72.6
Bu den pe ime
dedica ed o ca e 0.93 (15.25) ** 0.27 70.6 50.0 62.2
Pe sonal li e bu den 0.81 (41.02) ** 0.43 72.3 70.7 71.6
Physical bu den 0.77 (51.39) ** 0.48 68.1 73.2 70.1
Social bu den 0.80 (43.42) ** 0.44 66.4 73.2 69.2
Emo ional bu den 0.94 (11.97) * 0.24 43.7 80.5 58.7
No e: ** p< 0.001; * p= 0.001.
In . J. En i on. Res. Public Heal h 2019, 16, x FOR PEER REVIEW 8 o 17
sco es and g oup membe ship, was 0.53. This analysis co ec ly classi ied 72.6% o he cases (Table
3). The a ea unde he ROC cu e was 0.81 (95% CI 0.75–0.87; Figu e 2). Fo he cu -o poin o 39,
he es showed a sensi i i y o 75.6%, speci ici y o 74.4%, PPV o 81.1%, and NPV o 67.8% (Table
4).
Figu e 2. Recei e ’s Ope a ing Cha ac e is ics (ROC) Cu e o he o iginal CBI.
Rega ding subscales, he e was a posi i e co ela ion be ween emo ional dis ess and bu den
pe ime dedica ed o ca e ( = 0.244, p < 0.001), pe sonal li e bu den ( = 0.512, p < 0.001), physical
bu den ( = 0.583, p < 0.001), social bu den ( = 0.590, p < 0.001) and emo ional bu den ( = 0.306, p <
0.001). Ca egi e s wi h p obable cases o men al diso de , compa ed o hose wi hou i , had highe
bu den pe ime dedica ed o ca e, (199) = −3.99, p < 0.001, pe sonal li e bu den, (199) = −6.76, p <
0.001, physical bu den, (199) = −7.77, p < 0.001, social bu den, (197) = −7.33, p < 0.001, and emo ional
bu den, (193) = −3.65, p < 0.001.
Table 3. Disc iminan analysis and pe cen age o cases co ec ly classi ied o he o iginal CBI.
To al/Subscales Wilks’
Lambda (χ2)
Canonical
Co ela ion
P obable Cases o
Men al Diso de
No Cases o Men al
Diso de To al
To al bu den 0.72 (64.80) ** 0.53 69.7 76.8 72.6
Bu den pe ime dedica ed o ca e 0.93 (15.25) ** 0.27 70.6 50.0 62.2
Pe sonal li e bu den 0.81 (41.02) ** 0.43 72.3 70.7 71.6
Physical bu den 0.77 (51.39) ** 0.48 68.1 73.2 70.1
Social bu den 0.80 (43.42) ** 0.44 66.4 73.2 69.2
Emo ional bu den 0.94 (11.97) * 0.24 43.7 80.5 58.7
No e: ** p < 0.001; * p = 0.001.
Wilks’ lambda anged be ween 0.77 in physical bu den and 0.94 in emo ional bu den. The
canonical co ela ion was om 0.24 in emo ional bu den o 0.48 in physical bu den. The pe cen ages
o co ec ly classi ied cases anged be ween 58.7% and 71.6% (Table 3). The a ea unde he ROC cu e
was 0.68 (95% CI 0.61–0.74) o bu den pe ime dedica ed o ca e, 0.76 (95% CI 0.69–0.81) o pe sonal
li e bu den, 0.78 (95% CI 0.72–0.84) o physical bu den, 0.77 (95% CI 0.71–0.83) o social bu den and
0.67 (95% CI 0.60–0.73) o emo ional bu den. The cu o poin s o 16, 9, 8, 4, and 2 in he espec i e
subscales showed a sensi i i y be ween 63.0% and 74.0%, speci ici y be ween 63.4% and 72.0%, PPV
be ween 71.7% and 78.9% and NPV be ween 54.7% and 64.1 % (Table 4).
Table 4. P edic i e abili y o he cu -o poin s o he o iginal CBI.
Figu e 2. Recei e ’s Ope a ing Cha ac e is ics (ROC) Cu e o he o iginal CBI.
Table 4. P edic i e abili y o he cu -o poin s o he o iginal CBI.
To al/Subscales Cu -O Poin Sensi i i y Speci ici y Posi i e P edic i e
Value
Nega i e P edic i e
Value
To al bu den 39 75.6 74.4 81.1 67.8
Bu den pe ime
dedica ed o ca e 16 70.6 63.4 71.7 54.7
Pe sonal li e bu den 9 72.3 72.0 78.9 64.1
Physical bu den 8 72.3 65.9 75.4 62.1
Social bu den 4 74.0 65.9 75.9 63.5
Emo ional bu den 2 63.0 65.9 72.8 55.1
Rega ding subscales, he e was a posi i e co ela ion be ween emo ional dis ess and bu den
pe ime dedica ed o ca e ( = 0.244, p< 0.001), pe sonal li e bu den ( = 0.512, p< 0.001), physical
bu den ( = 0.583, p< 0.001), social bu den ( = 0.590, p< 0.001) and emo ional bu den ( = 0.306, p<
In . J. En i on. Res. Public Heal h 2019,16, 217 16 o 19
Po uguese [
24
] e sions. The co a iances be ween ac o s indica ed ha hey we e no edundan ,
e lec ing a mul idimensional ins umen , which is consis en wi h he mul idimensional de ini ion o
ca egi e bu den [10–12].
Addi ionally, we ound ha a highe le el o o al bu den in bo h he o iginal and he sho ened
e sion o he CBI and all o hei subscales excep bu den pe ime dedica ed o ca e o he sho ened
e sion we e associa ed wi h g ea e emo ional dis ess. Fu he , ca egi e s wi h a p obable men al
diso de case had signi ican ly highe sco es han hose who did no ha e a p obable case o
men al diso de on all subscales excep bu den pe ime dedica ed o ca e o he sho ened e sion.
These esul s indica e ha he CBI p esen s mo e concu en alidi y and speci ici y o e lec he
epe cussions o ca e on he wel a e o he ca egi e in he comple e e sion, which was consis en
wi h p e ious esea ch [
16
]. Finally, in he o iginal CBI he cu -o poin s o 39 in he o al sco e and
o 16, 9, 8, 4, and 2 in he subscales ( ime dedica ed o ca e, pe sonal li e bu den, physical, social,
and emo ional bu den) we e adequa e o disc imina e be ween ca egi e s wi h and wi hou p obable
men al diso de s. Ins ead, he 15-i em CBI showed sca ce disc imina ion capaci y: he cu -o poin s
p esen ed low sensi i i y (42.6%) in emo ional bu den and low speci ici y (43.9%) in bu den pe ime
dedica ed o ca e, wi h he consequen isk o alse posi i es and alse nega i es.
4.1. Implica ions
This s udy has impo an implica ions o esea ch, socie y and policymake s. I sugges s ha
he bu den bo ne by ca egi e s can be high enough o jus i y a e e al o p o essionals o p ope
e alua ion. The esul s show ha he eliabili y and alidi y o he Spanish e sion o he CBI we e
gene ally suppo ed, consis en wi h he o iginal English e sion o he ins umen . In addi ion,
a sho ened, 15-i em e sion o he CBI ha i be e wi h he cul u al con ex and sociodemog aphic
cha ac e is ics o he Spanish non-p o essional ca egi e s o dependen pe sons wi h a ious diseases
alidly measu ed ca egi e bu den. Gi en he eluc ance o ca egi e s o comple e long ques ionnai es
due o hei lack o a ailable ime, his 15-i em e sion p o ide a mo e pa simonious ins umen
which eliably included all ele an dimensions. The 15-i em e sion may imp o e e iciency o
adminis a ion, making i an a ac i e choice o esea che s and clinicians. Howe e , u u e esea ch
is needed o eplica e hese esul s o he sho ened e sion. Fu he mo e, i p o ides a cu -o poin
ha disc imina es ca egi e s wi h and wi hou p obable cases o men al diso de , al hough he esul s
o his s udy sugges ha he cu -o poin s o he 15-i em CBI should be used cau iously. Fu u e
s udies could analyze new cu -o poin s applicable o o he speci ic men al heal h p oblems.
The adminis a ion o his ins umen would p o ide de ailed in o ma ion on he
mul idimensional mani es a ions o bu den, acili a ing he iden i ica ion o di e en p o iles o
ca egi e s’ bu den. Policymake s could use his ins umen o unde s and he speci ic needs o he
ca egi e popula ion. In addi ion, he ins umen would also iden i y ca egi e s wi h excessi e bu den,
hus allowing he s udy o p o ec i e and isk ac o s. Fu he mo e, his ins umen is use ul o
esea che s and clinicians o dis inguish po en ial a eas o in e en ion o ca egi e s, which would
allow he de elopmen o in e en ions ailo ed o he needs o speci ic ca egi e s and he e alua ion
o ca egi e bu den pos -in e en ion. Gi en he high p e alence o ca egi e s in Spain (and o he
Spanish-speaking coun ies) [
1
,
25
], he Spanish e sion o he CBI bene i a la ge numbe o ca egi e s
in he p esen and he u u e.
4.2. Limi a ions
The cu en s udy is no wi hou limi a ions. We used he GHQ-12 o assess p obable cases o
men al diso de ins ead o a diagnos ic in e iew. Al hough his is a commonly used ins umen ,
i does no es ablish clinical diagnoses. In addi ion, he sel - epo ed na u e o he ins umen s used
could exace ba e he common a iance and a i icially inc ease he co ela ions be ween a iables [
44
].
Also, eliance on sel - epo ed ins umen s may in oduce esponse bias due o social desi abili y,
acquiescence and common scale ancho s. To educe hem, we ollowed ecommenda ions by Podsako ,

In . J. En i on. Res. Public Heal h 2019,16, 217 17 o 19
MacKenzie, Lee e al. [
45
], including p o ec ing esponden anonymi y, assu ing pa icipan s ha
he e we e no igh o w ong answe s and asking hem o answe ques ions as hones ly as possible.
Sel - epo ed ins umen s o p edic o and c i e ion measu es had di e en scale endpoin s and
o ma s, he p edic o measu emen (GHQ-12) had sound psychome ic p ope ies [
46
], and bipola
scale alues we e a oided. Ano he limi a ion is ha he size o he sample was insu icien o pe o m
a ya ds ick o he ins umen o add ess di e en demog aphic segmen s. Finally, he ac ha he
sample o ca egi e s was om one o egions o Spain (Galicia) limi s he ex e nal alidi y, al hough
he da a a ailable in o he egions o ou coun y ha e a simila demog aphic and clinical p o ile [
25
].
5. Conclusions
In conclusion, he esul s o his s udy p o ided e idence o a i e- ac o s uc u e and good
eliabili y o he i e subscales in he Spanish CBI. The 15-i em abb e ia ed e sion o he CBI has
accep able psychome ic p ope ies o assess he bu den on he popula ion o Spanish non-p o essional
ca egi e s o dependen pe sons wi h a ious diseases, hough i has a low capaci y o disc imina ion
be ween ca egi e s wi h and wi hou p obable men al heal h diso de .
Au ho Con ibu ions:
F.L.V. pa icipa ed in he in es iga ion, concep ualized he pape , conduc ed he analyses,
and w o e he o iginal d a . P.O. pa icipa ed in he in es iga ion, concep ualized he pape , conduc ed he
analyses and w o e he o iginal d a . M.A.S. pa icipa ed in he in es iga ion, helped in concep ualize he pape
and e iewed he ex c i ically. A.M.B. pa icipa ed in he in es iga ion, helped in concep ualize he pape and
e iewed he ex c i ically. V.B. pa icipa ed in he in es iga ion and e iewed he ex c i ically. All au ho s ha e
app o ed he inal a icle.
Funding:
Spin-o o he Uni e si y o San iago de Compos ela “Xun os. Psychological and Psychia ic Ca e”
(2013-CE081-4).
Acknowledgmen s: This esea ch was suppo ed om Minis y o Labou and Wel a e (Xun a de Galicia).
Con lic s o In e es : The au ho s decla e no con lic o in e es .
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