Psychometric Properties of the Spanish Version of the Caregiver Burden Inventory

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   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 . Re e ences 1. Ha wood, R.H.; Saye , A.A.; Hi sch eld, M. Cu en and u u e wo ldwide p e alence o dependency, i s ela ionship o o al popula ion, and dependency a ios. Bull Wo ld Heal h O gan. 2004 ,82, 251–258. [PubMed] 2. Chia i, C.; Rod íguez, D.; Malmg en, A.; Scandali, V.; Masse a, F.; Le hin, C. U iliza ion o o mal and in o mal ca e by communi y-li ing people wi h demen ia: A compa a i e s udy be ween Sweden and I aly. In . J. En i on. Res. Public Heal h. 2018,15, 2679. [C ossRe ] [PubMed] 3. Colombo, F.; Llena-Nozal, A.; Me cie , J.; Tjadens, F. Help Wan ed? P o iding and Paying o Long-Te m Ca e; OECD Publishing, OECD Heal h Policy S udies: Pa is, F ance, 2011. 4. O e o, P.; Smi , F.; Cuijpe s, P.; To es, A.; Blanco, V.; Vázquez, F.L. Long- e m e icacy o indica ed p e en ion o dep ession in non-p o essional ca egi e s: Randomized con olled ial. Psychol. Med. 2015 ,45, 1401–1412. [C ossRe ] [PubMed] 5. Vázquez, F.L.; To es, A.; Blanco, V.; O e o, P.; Díaz, O.; Fe aces, M.J. Long- e m ollow-up o a andomized clinical ial assessing he e icacy o a b ie cogni i e-beha io al dep ession p e en ion in e en ion o ca egi e s wi h ele a ed dep essi e symp oms. Am. J. Ge ia . Psychia y 2016 ,24, 421–432. [C ossRe ] [PubMed] 6. Ins i u e o he Elde ly and Social Se ices (Ed.) Cuidados a las Pe sonas Mayo es en los Hoga es Españoles. El En o no Familia [Ca e o he Elde ly in Spanish Homes. The Family En i onmen ]; Minis e io de T abajo y Asun os Sociales: Mad id, Spain, 2005. 7. Rod íguez-Mad id, M.N.; Del Río-Lozano, M.; Fe nández-Peña, R.; Jiménez-Pe ne , J.; Ga cía-Mochón, L.; Lupiañez-Cas illo, A.; Ga cía-Cal en e, M.D.M. Gende di e ences in social suppo ecei ed by in o mal ca egi e s: A pe sonal ne wo k analysis app oach. In . J. En i on. Res. Public Heal h 2019 ,16, 91. [C ossRe ] 8. G ad, J.; Sainsbu y, P. Men al illness and he amily. Lance 1963,1, 544–547. [C ossRe ] 9. Mon gome y, R.J.; Gonyea, J.G.; Hooyman, N.R. Ca egi ing and he expe ience o subjec i e and objec i e bu den. Fam. Rela . 1985,34, 19–26. [C ossRe ] In . J. En i on. Res. Public Heal h 2019,16, 217 18 o 19 10. Case a, M.S.; Lund, D.A.; W igh , S.D. Explo ing he Ca egi e Bu den In en o y (CBI): Fu he e idence o a mul idimensional iew o bu den. In . J. Aging Hum. De . 1996,43, 21–34. [C ossRe ] 11. Chou, K.R. Ca egi e bu den: A concep analysis. J. Pedia . Nu s. 2000,15, 398–407. [C ossRe ] 12. Mon o io, I.; Fe nández, M.; López, A.; Sánchez, M. La en e is a de ca ga del cuidado . U ilidad y alidez del concep o de ca ga [The Bu den In e iew. Use ulness and alidi y o he bu den concep ]. An. Psicol. 1998,14, 229–248. 13. Pea lin, L.I.; Mullan, J.T.; Semple, S.J.; Ska , M.M. Ca egi ing and he s ess p ocess: An o e iew o concep s and hei measu es. Ge on ologis 1990,30, 583–594. [C ossRe ] 14. Ca asco, M.; Balles e os, J.; Iba a, N.; Loizaga, C.; Se ano, B.; La umbe, M.J.; Aizco be, C.; Belenge , C. Sob eca ga del cuidado de pacien es con en e medad de Alzheime y dis és psíquico: Una asociación elegada en la alo ación de las demencias [Alzheime ’s ca egi e bu den and psychological dis ess: A neglec ed associa ion in he assessmen o demen ias]. Ac as Esp. Psiquia . 2002,30, 201–206. 15. Denno, M.S.; Guilla d, P.J.; G aham, G.D.; DiBona en u a, M.D.; Go en, A.; Va on, S.F.; Zo owi z, R. Anxie y and dep ession associa ed wi h ca egi e bu den in ca egi e s o s oke su i o s wi h spas ici y. A ch. Phys. Med. Rehabil. 2013,94, 1731–1736. [C ossRe ] [PubMed] 16. Ma a di, M.; Ma ioli, P.; Spazza umo, L.; Mas i o i, R.; Rinaldi, P.; Polido i, M.C.; Che ubini, A.; Qua esan, R.; Ba o elli, L.; Bonaiu o, S.; e al. The Ca egi e Bu den In en o y in e alua ing he bu den o ca egi e s o elde ly demen ed pa ien s: Resul s om a mul icen e s udy. Aging Clin. Exp. Res. 2005 ,17, 46–53. [C ossRe ] [PubMed] 17. Ri e a-Na a o, J.; Beni o-León, J.; O eia-Gue a a, C.; Pa do, J.; Dib, W.B.; O s, E.; Belló, M. Bu den and heal h- ela ed quali y o li e o Spanish ca egi e s o pe sons wi h mul iple scle osis. Mul . Scle . 2009 ,15, 1347–1355. [C ossRe ] [PubMed] 18. Özcan, N.K.; Boyacio˘glu, N.E.; Se çelik, E. Recip ocal abuse: Elde neglec and abuse by p ima y ca egi e s and ca egi e bu den and abuse in Tu key. A ch. Psychia . Nu s. 2017,31, 177–182. [C ossRe ] [PubMed] 19. No ak, M.; Gues , C.I. Applica ion o a mul idimensional Ca egi e Bu den In en o y. Ge on ologis 1989 ,29, 798–803. [C ossRe ] 20. Chou, K.R.; Chu, H.; Tseng, C.L.; Lu, R.B. The measu emen o ca egi e bu den. J. Med. Sci. 2003 ,23, 73–82. 21. C espo, M.; Ri as, M.T. La e aluación de la ca ga del cuidado : Una e isión más alláde la escala de Za i [Assessmen o ca egi e ’s bu den: A e iew beyond Za i ’s scale]. Clin Salud. 2015,26, 9–16. [C ossRe ] 22. Ma ín-Ca asco, M.; Domínguez-Panchón, A.I.; Muñoz-He moso, P.; González-F aile, E.; Balles e os-Rod íguez, J. Ins umen os pa a medi la sob eca ga en el cuidado in o mal del pacien e con demencia [Assessmen ools o measu e bu den in he in o mal ca egi e o pa ien s wi h demen ia]. Re . Esp. Ge ia . Ge on ol. 2013 ,48, 276–284. [C ossRe ] 23. Chou, K.R.; Jiann-Chyun, L.; Chu, H. The eliabili y and alidi y o he Chinese e sion o he Ca egi e Bu den In en o y. Nu s. Res. 2002,51, 324–331. [C ossRe ] [PubMed] 24. Vale , D.B.; Ai es, M.; Fengle , F.L.; Paskulin, L.M. Adap a ion and alida ion o he Ca egi e Bu den In en o y o use wi h ca egi e s o elde ly indi iduals. Re . La . Am. En e magem. 2015 ,23, 130–138. [C ossRe ] [PubMed] 25. Na ional Ins i u e o S a is ic. Encues a de Discapacidad, Au onomía pe sonal y si uaciones de Dependencia, 2008 [Su ey o Disabili y, Pe sonal Au onomy and Dependency Si ua ions, 2008]. A ailable online: h p: //www.ine.es/ e is as/ci aine/1009.pd (accessed on 1 Decembe 2018). 26. Goldbe g, D.; Williams, P. A Use ’s Guide o he Gene al Heal h Ques ionnai e; NFER-Nelson: Windso , UK, 1988. 27. Rocha, K.B.; Pé ez, K.; Rod íguez-Sanz, M.; Bo ell, C.; Obiols, J.E. P opiedades psicomé icas y alo es no ma i os del Gene al Heal h Ques ionnai e (GHQ-12) en población gene al española [Psychome ic p ope ies and no ma i e alues o he Gene al Heal h Ques ionnai e (GHQ-12) in he Spanish gene al popula ion]. In . J. Clin. Heal h Psychol. 2011,11, 125–139. 28. Goldbe g, D.P.; Ga e , R.; Sa o ius, N.; Us un, T.B.; Piccinelli, M.; Gu eje, O.; Ru e , C. The alidi y o wo e sions o he GHQ in he WHO s udy o men al illness in gene al heal h ca e. Psychol. Med. 1997 ,27, 191–197. [C ossRe ] [PubMed] 29. Hamble on, R.K. Issues, designs and echnical guidelines o adap ing es in o mul iple languages and cul u es. In Adap ing Educa ional and Psychological Tes o C oss-Cul u al Assessmen ; Hamble on, R.K., Me enda, P.F., Spielbe g, C.D., Eds.; E lbaum: Mahwah, NJ, USA, 2005; pp. 3–38. In . J. En i on. Res. Public Heal h 2019,16, 217 19 o 19 30. Guillemin, F.; Bomba die , C.; Bea on, D. C oss-cul u al adap a ion o heal h- ela ed quali y o li e measu es: Li e a u e e iew and p oposed guidelines. J. Clin. Epidemiol. 1993,46, 1417–1432. [C ossRe ] 31. Hamble on, R.K.; Zenisky, A. T ansla ing and adap ing es s o c oss-cul u al assessmen . In C oss-Cul u al Resea ch Me hods; Ma sumo o, D., an de Vij e , F., Eds.; Camb idge Uni e si y P ess: New Yo k, NY, USA, 2010; pp. 46–74. 32. In e na ional Tes Commission. The ITC Guidelines o T ansla ing and Adap ing Tes s. 2005. A ailable online: h ps://www.in es com.o g/ iles/guideline_ es _adap a ion.pd (accessed on 1 Decembe 2018). 33. B islin, R.W.; Lonne , W.J.; Tho ndike, E.M. C oss-Cul u al Resea ch Me hods; Wiley: New Yo k, NY, USA, 1973. 34. Hulley, S.B.; Cummings, S.R.; Newman, T.B. Designing c oss-sec ional and coho s udies. In Designing Clinical Resea ch, 4 h ed.; Hulley, S.B., Cummings, S.R., B owne , W.S., G ady, D.G., Newman, T.B., Eds.; Lippinco Williams & Wilkins: Philadelphia, PA, USA, 2013; pp. 85–96. 35. Hu, L.; Ben le , P.M. Cu o c i e ia o i indexes in co a iance s uc u e analysis: Con en ional c i e ia e sus new al e na i es. S uc . Equ. Model. 1999,6, 1–55. [C ossRe ] 36. By ne, B.M. S uc u al Equa ion Modeling wi h AMOS: Basic Concep s, Applica ions, and P og aming, 2nd ed.; Rou ledge: New Yo k, NY, USA, 2010. 37. Hai , J.F.; Black, B.; Babin, B.; Ande son, R.E.; Ta ham, R.L. Mul i a ia e Da a Analysis; Pea son P en ice Hall: Uppe Saddle Ri e , NJ, USA, 2006. 38. Chin, W.W. Pa ial leas squa es is o LISREL as p incipal componen s analysis is o common ac o analysis. Technol. S ud. 1995,2, 1–6. 39. Kline, R.B. P inciples and P ac ice o S uc u al Equa ion Modeling, 2nd ed.; Guild o d P ess: New Yo k, NY, USA, 2016. 40. Desai, A.K.; Schwa z, L.; G ossbe g, G.T. Beha io al dis u bance in demen ia. Cu . Psychia y Rep. 2012 ,14, 298–309. [C ossRe ] 41. Hays, R.D.; Ande son, R.; Re icki, D. Psychome ic conside a ions in e alua ing heal h- ela ed quali y o li e measu es. Qual. Li e Res. 1993,2, 441–449. [C ossRe ] 42. Raubenheime , J.R. An i em selec ion p ocedu e o maximise scale eliabili y and alid y. J. Ind. Psychol. 2004,30, 59–64. 43. Guadagnoli, E.; Velice , W.F. Rela ion o sample size o he s abili y o componen pa e ns. Psychol. Bull. 1988,103, 265–275. [C ossRe ] [PubMed] 44. Spec o , P.E. Me hod a iance in o ganiza ional esea ch: T u h o u ban legend? O gan. Res. Me hods 2006 , 9, 221–232. [C ossRe ] 45. Podsako , P.M.; MacKenzie, S.B.; Lee, J.Y.; Podsako , P. Common me hod biases in beha io al esea ch: A c i ical e iew o he li e a u e and ecommended emedies. J. Appl. Psychol. 2003 ,88, 879–903. [C ossRe ] [PubMed] 46. Rush, A.J.; Fi s , M.B.; Blacke , D. Handbook o Psychia ic Measu es, 2nd ed.; Ame ican Psychia ic Publishing: Washing on, DC, USA, 2008. © 2019 by he au ho s. Licensee MDPI, Basel, Swi ze land. This a icle is an open access a icle dis ibu ed unde he e ms and condi ions o he C ea i e Commons A ibu ion (CC BY) license (h p://c ea i ecommons.o g/licenses/by/4.0/).