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Psychiatry Research 200 (2012) 896903

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Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Validity and reliability of the Spanish version of the Involvement Evaluation

Questionnaire among caregivers of patients with eating disorders
Nerea Gonzalez a,n, Amaia Bilbao b, Angel Padierna c, Josune Martn a, Miren Orive a, Jose M Quintana a,d
a o
CIBER of Epidemiology and Public Health, Research Unit, Hospital Galdakao-UsansoloCIBERESP, B % Labeaga, s/n. 48960 Galdakao, Bizkaia, Spain
Research Unit, Hospital Universitario BasurtoCIBERESP, Bilbao, Bizkaia, Spain
Psychiatry Service, Hospital Galdakao-UsansoloCIBERESP, Galdakao, Bizkaia, Spain
Preventive Medicine and Public Health Department, University of the Basque Country, Leioa, Bizkaia, Spain

a r t i c l e i n f o a b s t r a c t

Article history: The Involvement Evaluation Questionnaire (IEQ) was developed to evaluate burden among caregivers
Received 2 March 2012 of patients with schizophrenia. We aimed to examine its psychometric properties among caregivers of
Received in revised form patients with eating disorders (ED). A prospective study was carried out, recruiting caregivers of
13 July 2012
patients with an ED attending two outpatient clinics in Bizkaia, Spain. Caregivers provided socio-
Accepted 23 July 2012
demographic information and completed the Involvement Evaluation Questionnaire (IEQ), the Hospital
Anxiety and Depression Scale (HADS), the Short-Form 12 (SF-12) and the Anorectic Behaviour
Keywords: Observation Scale (ABOS). The same information was requested one year later. The conrmatory factor
Caregiver analysis (CFA) provided satisfactory t indexes. Almost all of the factor loadings were above 0.40.
Cronbachs alpha coefcients were mostly superior to 0.70. The correlation coefcients between the IEQ
domains and the other questionnaires were lower than the Cronbachs alpha coefcients. Known-
Psychometric properties
groups validity was supported by signicant differences in the IEQ mean scores according to certain
variables, as contact hours, living with the patient, type of caregiver and gender. The indexes employed
for the evaluation of responsiveness were between 0.13 and 0.99. The IEQ has good psychometric
properties and can be used to evaluate burden among caregivers of patients with ED.
& 2012 Elsevier Ireland Ltd. All rights reserved.

1. Introduction Several instruments have been developed to evaluate caregiver

burden in different disorders (Vitaliano et al., 1991; Schene et al.,
Caring for a family member or other relative with a chronic 1994; Kinsella et al., 1998; Deeken et al., 2003; Haigh and
disorder can be a stressful endeavour associated with anxiety, Treasure, 2003; Visser-Meily et al., 2004; Sepulveda et al., 2008;
depression, and physical discomfort, not to mention continuing Sepulveda et al., 2009; Whalen and Buchholz, 2009).One such
concern for the health status of the aficted family member or instrument is the Involvement Evaluation Questionnaire (IEQ)
relative (Treasure, 2004; Hirst, 2005). This stress has been called (Schene and van Wijngaarden, 1992). The IEQ was initially
caregiver burden. Platt (1985), one of the rst to investigate this developed to measure the perception and consequences of care-
problem, dened caregiver burden as problems, difculties or giver burden among carers of patients with psychotic disorders
adverse events that affect the lives of a patients signicant (Schene and van Wijngaarden, 1992; Van Wijngaarden et al.,
others (Platt, 1985). Other authors, as Lazarus and Folkman 1996) where it showed a good reliability and validity, in terms of
(1984), have emphasised that the reaction to the stress the content and construct validity. The IEQ was translated into
caregiving causes is in some way mitigated by the ability of the Spanish and validated in Spain in this population (van
carer to perceive the situation as threatening or not. Whereas Wijngaarden et al., 2000), but these authors have only published
Platt (1985) deals with the experience of caregiving as something the reliability data of this version, with good results for the
essentially negative, Lazarus and Folkman (1984) consider differ- internal consistency and the testretest reliability. Recently, this
ences depending on the way the carer faces and evaluates the questionnaire has been validated in caregivers of brain injured
situation; those caregivers who perceive the caregiving experi- patients, showing also good data on reliability and validity, and
ence as positive, would perceive less burden. moderate for responsiveness (Geurtsen et al., 2010). In both cases,
the number of factors was the same as in the original version of
the questionnaire.
Corresponding author. Tel.: 34 94007105; fax: 34 944007132. The IEQ has also been used among caregivers of patients with
E-mail address: nerea.gonzalezhernandez@osakidetza.net (N. Gonzalez). affective disorders (van Wijngaarden et al., 2004; Cleary et al.,

0165-1781/$ - see front matter & 2012 Elsevier Ireland Ltd. All rights reserved.
N. Gonzalez et al. / Psychiatry Research 200 (2012) 896903 897

2006; van Wijngaarden et al., 2009) and eating disorders (ED) Spanish population (Quintana et al., 2003), with Cronbachs alpha coefcients of
0.86 both for anxiety and depression.
(Martn et al., 2011; Padierna et al., in press), but it has not yet
The Short-Form 12 (SF-12) (Ware et al., 1996) is a 12-item instrument designed
been validated in the latter population, so our hypothesis was to measure general health-related quality of life (HRQoL). Answers provide two
that this questionnaire could also show good psychometric summary scores, the mental component scale (MCS) and physical component
properties for carers of patients with ED. scale (PCS), which reect the individuals perceived mental and physical health.
The primary aim of our study was to evaluate several psycho- Scores range from 0 to 100 on each subscale. The higher the score, the more
positive the perception of health. We used a version of the SF-12 validated in
metric properties of the IEQ in a sample of caregivers of patients Spanish (Gandek et al., 1998; Vilagut et al., 2008) and its Cronbachs alpha
with EDs: (a) internal consistency reliability (Cronbachs alpha, coefcients were 0.85 for the physical component scale and 0.78 for the mental
and intercorrelations between scales); (b) construct validity component scale.
(conrmatory factor analysis (CFA), convergent and discriminant The Anorectic Behaviour Observation Scale (ABOS) (Vandereycken, 1992) is used to
evaluate a patients eating behaviour based on information provided by his or her
validity), and (c) responsiveness.
caregiver. The ABOS consists of 30 items in three domains: factor Ieating behaviour,
concern with weight and foods, and denial of problems; factor IIbulimic-like
behaviour; and factor IIIhyperactivity. Questions are to be answered yes (2 points)
2. Method or no (0 points) if the person is certain of the answer, and ? (1 point) if he or she is
uncertain about it. Scores range from 0 to 60; the higher the score, the greater the
2.1. Subjects patients pathology. The authors of the original version proposed that a score of 19 or
higher identied a patient with an ED (Vandereycken, 1992). This questionnaire has
been translated into Spanish (Instituto Nacional de la Salud, 1995).
This prospective study recruited caregivers of patients attending the Eating
Disorders Outpatient Clinic of the Psychiatric Services at Galdakao-Usansolo
Hospital and Ortuella Mental Health Center in Bizkaia, Spain. Both are part of 2.3. Procedure
the network of public health-care centres of the Basque Health Service, which
provides unlimited free care to nearly 100% of the population. Data collection started in 2007; one-year follow-ups were conducted through
Caregivers were considered for inclusion if they were a primary caregiver for 2008. Psychiatrists collaborating in the study informed their patients about the
an outpatient diagnosed with an ED, obtained consent to participate in the study objectives of the study and requested the participation of their primary caregivers.
from the patient for whom they were caring, and provided written informed Those who agreed to take part in the study received the questionnaires and the
consent to participate. According to criteria established by Perlick et al. (2005), a informed consent form by mail. They were asked to return these by mail using an
primary caregiver is dened as a person who fulls three or more of the following enclosed, pre-stamped envelope. Caregivers who did not return the information
criteria: (1) is the patients parent, partner, or other relative; (2) maintains within 20 days were sent a reminder letter.
frequent contact with the patient; (3) provides signicant nancial support to The same documents were mailed to participants one year after the rst round
the patient; (4) is the person most often present with the patient during of information gathering. As before, those who did not return the information
consultation or treatment and who is aware of the severity of the illness within 20 days were sent a reminder letter.
(accompanies the patient to medical appointments, participates in consultations
and therapy, supervises eating behaviour at home, etc.); and (5) is one of the
individuals the therapy team should contact in the event of an emergency. As part 2.4. Statistical analysis
of our units standard protocol, all ED caregivers receive professional counselling
from clinicians to deal with their relatives ED. Caregivers were excluded if they The statistical description of the sample was done using means and standard
had a malignant, severe organic disease, could not complete the questionnaires deviations (S.D.s), frequencies, and percentages.
due to language barriers, or did not give written informed consent. The construct validity of the IEQ was evaluated by means of a conrmatory
The institutional review board of Galdakao-Usansolo Hospital approved this factor analysis (CFA) for categorical variables to conrm the hypothesis that the 27
project. items on the questionnaire did, indeed, comprise four factors as proposed by the
original authors (Schene and Wijngaarden, 1992; van Wijngaarden et al., 2000).
Four indexes of t were evaluated (Mulaik, 1989; Hatcher, 1994; Devins et al.,
2.2. Materials 2001; Batista-Foguet et al., 2004): (a) w2 test divided by the degrees of freedom,
the result of which had to be r 2 to be acceptable; (b) the root mean squared error
Each caregiver was asked to provide sociodemographic information, including of approximation (RMSEA), where a value o0.08 was considered acceptable;
age, gender, marital status, level of education, relationship with the patient, (c) the comparative t index (CFI) and (d) the TuckerLewis Index (TLI), both of
whether he or she lived with the patient, and number of contact hours per week which had to be 40.90 to be satisfactory. Factor loadings were also examined, and
he or she had with the patient (o 32 or Z32 h). Caregivers were also asked to those Z 0.40 were considered acceptable. The model was considered acceptable if
complete four questionnaires. it surpassed these criteria.
The Involvement Evaluation QuestionnaireEU Version (IEQ-EU) (Schene and Reliability was assessed with Cronbachs alpha coefcient (Cronbach, 1951). A
Wijngaarden, 1992; Van Wijngaarden et al., 1996; van Wijngaarden et al., 2000) coefcient 40.70 was considered acceptable (Nunnally and Bernstein, 1994).
measures the psychosocial burden of caregiving. This self-reported questionnaire The convergent and discriminant validity of the IEQ domains were explored by
is scored on a ve-point Likert scale. It can be summarised into four distinct their correlations with each other, as well as with the SF-12, HADS and ABOS
domains: Tension (9 items; score range from 0 to 36), which refers to strains in the domains. We established that correlations between the IEQ domains and the other
interpersonal atmosphere between the patient and the caregiver; Supervision measures must be lower than the internal consistency of the IEQ scales, as
(6 items; score range from 0 to 24), which evaluates the caregivers task of measured by Cronbachs alpha (Fayers and Machin, 2000). We expected that the
guarding the patient; Worrying (6 items; score range from 0 to 24), which covers IEQ domains would correlate more strongly with each other, then with the HADS
the caregivers concerns about the patients safety, future, and health; and Urging and the ABOS, and lowest with the SF-12. The Spearman correlation coefcient
(8 items; score range from 0 to 32), which assesses the caregivers need to prompt was used.
or encourage the patient to undertake activities. Two items load on two subscales. For known-groups validity, we expected that the IEQ would capture the
A total score for the 27 items can be calculated by summing the answers to all of difference between caregivers divided by different criteria: (a) weekly contact
the items, with higher score indicating a higher burden perception (score range hours with the patient, (b) living with the patient, (c) gender, and (d) type of
from 0 to 108). This questionnaire has been translated into Spanish and validated caregiver. Following the results found in other studies (Schene et al., 1998; Lowyck
in Spain among caregivers of patients with schizophrenia (van Wijngaarden et al., et al., 2004; Gutierrez-Maldonado et al., 2005; Roick et al., 2006) and the
2000), where it showed good internal consistency and adequate testretest experience of the clinicians of our team, we hypothesised that the IEQ scores
reliability. Cronbachs alpha coefcients of this Spanish version were between would be higher (greater perception of caregiver burden) for caregivers with more
0.68 and 0.87. contact hours, those who lived with the patient, women, and mothers, or partners.
The Hospital Anxiety and Depression Scale (HADS) was designed to measure Therefore, the IEQ mean scores were compared among the different subgroups by
anxiety and depression in nonpsychiatric settings (Zigmond and Snaith, 1983). It the t-test or the analysis of variance (ANOVA) with Scheffe test for multiple
includes 14 items7 for evaluating anxiety and 7 for depression. All items are comparisons, or the non-parametric Wilcoxon test or KruskalWallis test if the
presented in a Likert format with four possible responses ranging from 0 to 3. assumption of normality was not met.
Thus, the possible score ranges from 0 to 21 for both the anxiety and depression We compared principal characteristics between caregivers who responded to
subscales. A score of 07 on a subscale is considered normal (indicating the the follow-up and those who did not. We used the w2 test or the Fisher exact test
absence of anxiety or depression); a score of 8, 9, or 10 indicates a possible case of for the comparison of categorical variables, and the t-test or the non-parametric
anxiety or depression; and a score of 11 or higher indicates the presence of anxiety Wilcoxon test for the comparison of quantitative variables. Means and S.D.s were
or depression (Zigmond and Snaith, 1983). The validity and reliability of the HADS calculated for the IEQ domains at baseline and at one-year follow-up, and a paired
have been conrmed (Herrmann, 1997), and it has been adapted and validated in a t-test was used for the comparison of scores at those two time points. Ceiling and
898 N. Gonzalez et al. / Psychiatry Research 200 (2012) 896903

oor effects at baseline and at one-year follow-up were examined to evaluate the 3.2. Reliability
discriminatory ability of the scales. To measure the responsiveness of the IEQ
domains, we used the standardised effect size (SES), dened as the mean change
score divided by the S.D. of the baseline scores, and the standardised response Four of the IEQ domains exceeded the minimum Cronbachs
mean (SRM), dened as the mean change score divided by the S.D. of the change alpha coefcient of 0.70: tension (0.76), supervision (0.80),
scores (Guillemin et al., 1993). Cohens benchmarks were used to classify the worrying (0.81) and total (0.84). Urging (0.66) did not.
magnitude of the effect sizes (Cohen, 1992): not signicant, below 0.20; small,
between 0.20 and 0.50; moderate, between 0.50 and 0.80; and large, above 0.80.
Having in mind that anxiety was one of the main variables with inuence in the
change in burden perception (Gonzalez et al., 2012), we decided to perform the 3.3. Convergent and discriminant validity
responsiveness study separately according to groups dened by the HADS anxiety
scale as follows: those patients with baseline score 410 and follow-up score r 10
were classied as improved; those with baseline score r10 and follow-up score
Correlation coefcients between the IEQ domains and the other
410 were considered worsened; and those with baseline and follow-up scores questionnaires (HADS, ABOS, and SF-12) were all lower than the
r 10 or with baseline and follow-up scores 410 were classied as equal. We Cronbachs alpha coefcients of the IEQ subscales (Table 3).
hypothesised that both SES and SRM results would be higher among improved As expected, the highest correlations were between the
patients than among patients classied as unchanged.
tension and worrying domains of the IEQ, with a correlation
Effects were considered signicant at po 0.05. All statistical analyses were
performed with SAS for Windows statistical software, version 9.2 (SAS Institute, coefcient of 0.57.The IEQ subscales correlated higher with the
Inc., Cary, NC), except the conrmatory factor analysis for categorical variables, for HAD and the ABOS questionnaires (r between 0.52 and 0.06)
which we used Mplus version 6.1 software (Muthen and Muthen, 1998, Los and lower with the SF-12 (r between  0.40 and  0.07).

3.4. Known-groups validity

3. Results The differences in the mean IEQ scores were statistically

signicant according to the variables used to evaluate known-
The sample included 309 caregivers, 246 of whom completed groups validity. As hypothesised, greater burden perceptions
the questionnaires at baseline (79.6%), and 143 did it also at the were observed in the total score and the urging domain for
follow-up (58.1%). The dropouts at the beginning of the study caregivers with 32 or more hours of contact per week with the
were caused mainly because patients did not gave their consent ED patient (p 0.003); in the tension domain for those living with
to their carers to participate, and in the follow-up because the the patient (p 0.004), in supervision for caregivers who were the
difculties to locate the caregivers due to changes in their patients partner (p 0.003) and for females (p 0.42); and in the
addresses or telephones, or because the caregivers did not want worrying domain for mothers (p0.033) and females (p 0.008).
to continue participating in the study. The global burden perception measured by the total score
The basic descriptive information of the sample is presented in obtained statistically signicant differences in all the variables,
Table 1. More than half (53.25%) of the caregivers were women except living with the patient (Table 4).
and 51.63% were between 46 and 60 years. The majority (85.66%)
of the caregivers lived with the patient, and 55% spent less than
32 h per week with the patient. Means for the IEQ subscales were
7.39 for tension, 2.37 for supervision, 12.23 for worrying, 6.75 for 3.5. Responsiveness
urging and 26.64 for the total subscale. In the patient sample, the
majority were women (98.6%), with a mean age of 25.73. Three Signicant differences were observed in anxiety and depres-
main diagnoses were detected, 44.14% of the patients having sion between caregivers who completed the questionnaires at the
anorexia nervosa, 24.83% had bulimia nervosa and 31.03% had an beginning of the study and after one year of follow-up and those
EDNOS. The clinician evaluated that the illness was severe in who did not complete the questionnaires at the one-year follow-
37.93% of the patients. And, nally, the 56.25% of the patients up (Table 1). Mean HADS anxiety scores were 8.75 74.30 in one-
begun with the disorder more than 5 years ago. year respondents vs 6.83 74.27 in nonrespondents; mean depres-
sion scores were 6.0574.05 in one-year respondents vs
4.5573.66 in nonrespondents. Differences were also observed
in the MCS of the SF-12, with mean scores of 42.41 710.52 in
3.1. Construct validity: conrmatory factor analysis one-year respondents and 46.7279.69 in nonrespondents. No
statistically signicant differences were observed in IEQ scales.
The results of the CFA provided satisfactory t indexes Both ceiling and oor effects of the four domains were generally
(Table 2). w2 divided by the degrees of freedom was 1.86, less low, except for supervision, which showed high oor effects at
than the benchmark of 2. The RMSEA values were less than 0.08, baseline (37.14%) and follow-up (46.72%). The responsiveness
while CFI and TLI both exceeded the benchmark of 0.90. All factor information is presented in Table 5, according to groups dened
loadings were statistically signicant (p o0.05) and almost all of by baseline and follow-up HADS anxiety scale, in order to
the factor loadings were above the criteria of 0.40 (range 0.22 evaluate if the questionnaire detects a change when another
0.90), which supported the stability of the structure of this instrument does. Since the sample size in the worsened group
questionnaire in this sample. Although Items 15 (Encouraged to was too small, the responsiveness study was not performed in
eat enough) and 41 (Worried about ones own future) did not this group. After one year of follow-up, in the unchanged group
reach the minimum factor loading required, both were higher mean scores on the IEQ scales decreased signicantly in the
than 0.30 (0.33 and 0.36, respectively). The lowest factor loading tension (1.16 points), worrying (2.63 points), urging domains
was found with item 20 (Ensuring that patients take the required (1.24 points), and the total score (4.86), but not in the supervision
medicine), which had a factor loading of 0.25. Items 28 and 42, domain (0.48 points; p 0.054). These changes were higher in
which the authors of the original version assigned each to two those patients who improved in anxiety, being the differences
different factors, clearly loaded in one of them: item 28 statistically signicant in all the subscales. The SES and SRM
(Disturbed carers sleep) in the supervision domain and item indexes of the IEQ were between 0.10 and 0.52 for the unchanged
42 (Global burden) in the tension domain. group, and between 0.38 and 0.99 for the improved group.
N. Gonzalez et al. / Psychiatry Research 200 (2012) 896903 899

Table 1
Descriptive data.

Respondents at baseline Respondents at follow-up Non-respondents at follow-up p value

(n 246) (n 143) (n 103)

Gendera (female) 131 (53.25) 78 (54.55) 53 (45.45) 0.698

Agea 0.088
r45 82 (33.33) 40 (27.97) 42 (40.78)
4660 127 (51.63) 78 (54.55) 49 (47.57)
460 37 (15.04) 25 (11.65) 12 (17.48)

Marital statusa 0.126

Single 33 (13.41) 13 (9.09) 20 (19.42)
Spouse/partner 191 (77.64) 117 (81.82) 74 (71.84)
Divorced 11 (4.47) 6 (4.20) 5 (4.85)
Widowed 11 (4.47) 7 (4.90) 4 (3.88)

Educational levela 0.958

No studies/primary education 100 (41.49) 60 (42.25) 40 (40.40)
Secondary education 53 (21.99) 31 (21.83) 22 (22.22)
University education 88 (36.51) 51 (35.92) 37 (37.37)

Relationship to the patienta 0.145

Mother 111 (45.12) 68 (47.55) 43 (41.75)
Father 70 (28.46) 45 (31.47) 25 (24.27)
Spouse/partner 34 (13.82) 16 (11.19) 18 (17.48)
Otherc 31 (12.60) 14 (9.79) 17 (16.50)

Living with patienta 0.713

Yes 209 (85.66) 122 (86.52) 87 (84.47)
No 35 (14.34) 19 (13.48) 16 (15.53)

Weekly contact hours with the patienta 0.149

o32 132 (55) 70 (50.72) 62 (60.78)
Z32 108 (45) 68 (49.28) 40 (39.22)

Anxiety 7.94 (4.38) 8.75 (4.30) 6.83 (4.27) 0.001
Depression 5.42 (3.95) 6.05 (4.05) 4.55 (3.66) 0.003

Factor I 12.73 (6.43) 13.34 (6.26) 11.89 (6.60) 0.101
Factor II 4.86 (3.46) 5.04 (3.29) 4.61 (3.68) 0.179
Factor III 4.92 (3.44) 5.10 (3.34) 4.67 (3.57) 0.327
Total 22.51 (10.46) 23.52 (9.89) 21.08 (11.13) 0.071

MCS 44.23 (10.38) 42.41 (10.52) 46.72 (9.69) 0.002
PCS 52.05 (7.56) 51.64 (8.07) 52.62 (9.69) 0.497

IEQ-EU Scalesb
Tension 7.39 (4.77) 7.66 (4.73) 7.01 (4.82) 0.289
Supervision 2.37 (3.76) 2.31 (3.80) 2.47 (3.72) 0.850
Worrying 12.23 (5.87) 12.69 (5.87) 11.60 (5.83) 0.138
Urging 6.75 (4.44) 6.97 (4.44) 6.44 (4.44) 0.465
Total 26.64 (13.40) 27.38 (13.48) 25.60 (13.28) 0.391

SF-12 (PCS): Physical Component Score of the SF-12. SF-12 (MCS): Mental Component Score of the SF-12.
ABOS score ranges: Factor I (Eating behaviour, concern with weight and foods, denial of problems) 032; Factor II (Bulimic-like behaviour) 014; Factor III (Hyperactivity)
014; Total 032.
IEQ score ranges: Tension 036; Supervision 024; Worrying 024; Urging 032; Total 0108.
These variables are presented as frequencies and percentages.
These variables are presented as means and standard deviations.
Other: sibling or child of the ED patient.

4. Discussion subscales are measuring the same concept. Other reliability

parameters of the IEQ could be evaluated in future studies in
The IEQ was originally created to evaluate the burden imposed carers of patients with ED to add further evidence of its quality.
by providing care to a family member with a psychotic The validity results were also good. The CFA results conrmed
or affective disorder (Schene and van Wijngaarden, 1992; the hypothesised internal structure of the four latent factors of
van Wijngaarden et al., 2004). To see if this instrument could be the original version of the IEQ (Schene et al., 1998) tension,
used in other caregiver populations, we applied it to a sample of worrying, supervision, and urging given that the t indexes
individuals caring for patients with ED. Our results suggest that were satisfactory and almost all factor loadings exceeded the
the IEQ is a useful instrument for assessing caregiver burden in recommended criteria (Hatcher, 1994; Batista-Foguet et al.,
this group. 2004). Only two items, 15 (Encouraged to eat enough) and 20
The reliability estimates were high, in line with standard (Ensured they take the required medicine), fell short of those
criteria for reliability (Cronbach, 1951). They were also similar criteria. Item number 20 was initially included in the supervision
to those of the original version of the IEQ (Van Wijngaarden et al., factor (Schene et al., 1998). In later papers, however, the authors
1996) and to the Spanish version (van Wijngaarden et al., 2000). of the original version of the IEQ incorporated this item in the
These data indicate that the items included in each of the urging factor (van Wijngaarden et al., 2000; Van Wijngaarden
900 N. Gonzalez et al. / Psychiatry Research 200 (2012) 896903

Table 2
Conrmatory factor analysis: factor loadings and t indexes (n 246).

Items Factor 1: Tension Factor 2: Supervision Factor 3: Worrying Factor 4: Urging

29: Strained atmosphere 0.89

30: Quarrels caused by patient 0.87
31: Carer annoyed by behaviour 0.90
32: Other annoyed by behaviour 0.44
33: Felt threatened by the patient 0.68
34: Considered moving out 0.63
41: Worried about ones own future 0.36
42: Global burden 0.43 0.28
21: Guarded from committing dangerous acts 0.82
22: Guarding from self-harm 0.86
23: Ensured sufcient sleep 0.64
24: Guarding from alcohol misuse 0.85
25: Guarding from taking illegal drugs 0.88
28: Disturbed carers sleep 0.22 0.57
36: Worried about patients safety 0.77
37: Worried about kind of treatment 0.78
38: Worried about patients general health 0.88
39: Worried about how they would manage nancially without your help 0.62
40: Worried about patients future 0.78
15: Encouraged to eat enough 0.33
16: Helped patient to take proper care of himself or herself 0.68
17: Urged patient to take proper care of himself or herself 0.70
18: Encouraged patient to undertake an activity 0.76
19: Accompanied patient on an outside activity 0.63
20: Ensured that patient take the required medicine 0.25
26: Carried out tasks normally done by the patient 0.60
27: Encouraged patient to get up in the morning 0.70
v2 (d.f.) 583.799 (314)
RMSEA (90% CI) 0.067 (0.0580.075)
Comparative t index 0.91
TLI 0.90

Factor 1: Tension. Factor 2: Supervision. Factor 3: Worrying. Factor 4: Urging.w2: Chi-square; d.f.: degrees of freedom.
RMSEA: root mean square error of approximation; CI: condence interval; TLI: TuckerLewis Index.
Correlation between the four latent factors is set to be different from 0, therefore four latent factors are specied to be intercorrelated. Covariance was specied between
the error items of the following two pair of items: Item 40 (Worried about patients future) and 41 (Worried about ones own future), and items 24 (Guarding from alcohol
misuse) and 33 (Felt threatened by the patient).

Table 3 structure that the authors of the IEQ used in their last reports,
Convergent and discriminant validity (n 246).
maintaining item 20 in the urging factor. In addition, items 28 and
IEQ scales
42, which in the original version contributed each to two different
factors, in our sample clearly loaded in one of them, suggesting
Tension Supervision Worrying Urging Total that item 28 (disturbed caregivers sleep) is better suited in the
supervision domain and item 42 (global burden) performs best in
the tension domain.
Tension 0.76y
Supervision 0.39* 0.80 Convergent and discriminant validities were assessed by exam-
Worrying 0.57* 0.36* 0.81 ining the correlations of the IEQ domains with those of the HADS,
Urging 0.41* 0.44* 0.39* 0.66 ABOS, and SF-12. The correlation coefcients of the IEQ subscales
Total 0.76* 0.61* 0.83* 0.72* 0.84
with each other and with other questionnaires were all lower than
SF-12 the Cronbachs alpha coefcients, supporting the validity of the IEQ
MCS  0.40*  0.37*  0.28*  0.26*  0.40* for assessing caregiver burden among caregivers of patients with ED.
PCS  0.17*  0.10  0.23*  0.07  0.17*
It must be noted that although all the correlations were statistically
HADS signicant, almost all of them were weak. They were, however,
Anxiety 0.44* 0.30* 0.42* 0.34* 0.49*
similar to those shown in other studies using the IEQ (Parabiaghi
Depression 0.41* 0.30* 0.38* 0.23* 0.43*
et al., 2007; Goossens et al., 2008). Finally, we evaluated the known-
ABOSa group validity in order to estimate how well the IEQ discriminates
Total 0.51* 0.30* 0.39* 0.23* 0.47*
Factor I 0.52* 0.25* 0.36* 0.21* 0.44*
between groups. As other authors have observed (Schene et al.,
Factor II 0.31* 0.35* 0.29* 0.29* 0.39* 1998; van Wijngaarden et al., 2009), the IEQ demonstrated that
Factor III 0.25* 0.06 0.20*  0.06 0.19* women, partners and mothers, caregivers living with the ED patient,
and those with more weekly contact hours with the patient had
Data are given as Spearman correlation coefcients.
higher perceived caregiver burden. However, there are several non-
Numbers in bold represent the Cronbachs alpha coefcients.
signicant differences that warrant further evaluation in future
Correlations are statistically different from 0 (p o 0.05).

ABOS domains: Factor I, Eating behaviour, concern with weight and foods, studies, as it could be expected, for instance, that caregivers with
denial of problems; Factor II, Bulimic-like behaviour; Factor III, Hyperactivity. more contact hours with the patients could feel more tension, or
those living with the patients could tend to supervise them more.
et al., 2002; van Wijngaarden et al., 2004; van Wijngaarden et al., The responsiveness parameters were low in the unchanged
2009). We performed the CFA analysis with both options and, group and moderate in the improved group, which can be a
since the results were similar in both cases, we maintained the reection of the small changes detected by the questionnaire over
N. Gonzalez et al. / Psychiatry Research 200 (2012) 896903 901

Table 4
Known-groups validity.

n IEQ scales

Tensiona Supervisiona Worryinga Urginga Total

Contact hours
o32 132 7.15 (5.09) 2.18 (3.19) 11.60 (5.80) 5.88 (3.74) 24.82 (13.02)
Z32 108 7.55 (4.24) 2.56 (4.22) 12.84 (5.90) 7.82 (4.98) 28.52 (13.36)
p value 0.146 0.326 0.083 0.003 0.028

Living with the patient

Yes 209 7.66 (4.58) 2.38 (3.67) 12.19 (5.69) 6.89 (4.36) 26.93 (12.92)
No 35 5.74 (5.67) 2.44 (4.42) 12.44 (7.00) 5.96 (4.93) 24.96 (16.33)
p value 0.004 0.143 0.891 0.115 0.198

Type of caregiver
Mother 111 7.83 (5.04) 2.76 (4.13) 13.42 (6.01) 7.20 (5.06) 28.78 (14.58)
Father 70 6.23 (3.89) 1.47 (2.72) 11.47 (5.90) 5.74 (3.75) 23.15 (12)
Spouse/partner 34 7.07 (4.12) 3.37 (4.61) 11.31 (4.86) 6.84 (3.77) 26.34 (11.51)
Others 31 8.86 (5.80) 1.91 (2.90) 10.81 (5.76) 7.29 (3.95) 27.23 (12.82)
p value 0.088 0.003 0.033 0.159 0.039

Female 131 7.98 (5.21) 2.70 (4) 13.14 (5.97) 7.32 (4.91) 28.80 (14.40)
Male 115 6.72 (4.13) 2.01 (3.45) 11.21 (5.60) 6.09 (3.75) 24.18 (11.75)
p value 0.081 0.042 0.008 0.106 0.006

Results are presented as means (standard deviations).

IEQ score ranges: Tension 036; Supervision 024; Worrying 024; Urging 032; Total 0108. p-values in bold represent statistically signicant differences.

Table 5
Responsiveness parameters after one year of follow-up, by change in the anxiety subscale of the HADS (n 143).

IEQ subscalesa

Tension Supervision Worrying Urging Total

Equal groupb
Mean (SD)y
Baseline 7.20 (4.37) 2.12 (3.66) 12.64 (5.89) 6.89 (4.49) 26.57 (13.20)
1 year follow-up 6 (4.45) 1.74 (3.39) 10.14 (6.27) 5.70 (4.40) 21.54 (13.61)
Change 1.16 (4.08) 0.36 (2.50) 2.63 (5.44) 1.24 (3.44) 4.86 (9.39)
p value 0.003 0.215 o 0.0001 0.0002 o0.0001
SES 0.27 0.10 0.45 0.28 0.37
SRM 0.28 0.14 0.48 0.36 0.52

Improved groupb
Mean (SD)y
Baseline 9.99 (6.11) 3.59 (4.93) 12.69 (5.61) 8.32 (4.60) 32.6 (15.35)
1 year follow-up 5.24 (3.45) 1.69 (2.92) 9.71 (6.15) 5.37 (3.10) 20.68 (11.74)
Change 4.75 (5.40) 1.87 (4.33) 2.98 (5.08) 2.71 (4.26) 11.91 (12.05)
p Value 0.0004 0.018 0.005 0.013 0.0001
SES 0.78 0.38 0.53 0.59 0.78
SRM 0.88 0.43 0.59 0.64 0.99

SD standard deviation; SES: standardized effect size; SRM: standardized response mean.
Changes were calculated by subtracting postintervention scores from preintervention scores; a positive result indicates a gain.
IEQ score ranges: Tension 036; Supervision 024; Worrying 024; Urging 032; Total 0-108.
Paired t-test to compare the mean at baseline and one year follow-up.
Equal group: those caregivers without changes in anxiety between baseline and follow-up, measured by the HADS; improved group: those caregivers who improved
in anxiety in the follow-up, measured by the HADS.

the course of one year on caregivers of ED patients. Other studies The authors of the IEQ began using it in psychosis, then used it for
using different questionnaires have also found small changes in affective disorders without validating it again, as they stated
the health status of ED patients with the follow-up periods they there were some similarities between these two disorders that
have used (Padierna et al., 2002; Las Hayas et al., 2007; Sepulveda could demonstrate its suitability for depression. In the case of
et al., 2008). If the mean evolution time for ED is 5 years brain injury, the authors performed a psychometric analysis
(Steinhausen, 2002; Steinhausen and Weber, 2009), the caregiver which yielded results similar to ours, with good reliability
burden perception could also need a longer follow-up period than estimates (Cronbachs alpha coefcients between 0.69 and 0.76),
the one used in our study to detect clinically signicant changes. low correlations with other questionnaires (r coefcient range
Although the IEQ was initially developed for evaluating the  0.29 0.40) and weak effect sizes (Cohens d effect size of 0.36).
burden imposed by providing care to patients with schizophrenia, Several instruments have been developed specically for ED
this instrument has also been used with caregivers of patients caregivers. The Carers Needs Assessment Measure (CaNAM) uses
with affective disorders (van Wijngaarden et al., 2004; van 14 items to evaluate the needs of ED carers (Haigh and Treasure,
Wijngaarden et al., 2009) or brain injury (Geurtsen et al., 2010). 2003). The Accommodation and Enabling Scale for Eating
902 N. Gonzalez et al. / Psychiatry Research 200 (2012) 896903

Disorders (AESED) measures families behaviours of accommoda- Acknowledgments

tion and enabling using 33 items (Sepulveda et al., 2009). Neither
of these instruments, however, measure caregiver burdenthe This study was partly funded by the Instituto de Salud Carlos
CaNAM measures met and unmet needs and the AESED evaluates III (project PI06/0921). We thank the Research Committee of the
families behaviours. In contrast, the 24-item Eating Disorders Galdakao-Usansolo Hospital for help editing this article and the
Symptom Impact Scale (EDSIS) was created specically to evalu- editorial assistance provided by Patrick Skerrett. Also, we would
ate the burden and consequences of caring for a family member like to thank Dr. van Wijngaarden, one of the authors of the
with an ED (Sepulveda et al., 2008). Looking at the construct original version of the Involvement Evaluation Questionnaire, for
measured by each questionnaire, the EDSIS could be the best to t answering all our questions in a very timely and precise way.
the aim of our study. However, EDSIS results had not been Most important, we are very grateful to the caregivers of patients
published when we began our study. At that time, the IEQ with eating disorders who collaborated in this study.
appeared to be the best instrument available, so we decided to
validate it in our sample of caregivers of patients with ED.
Both the EDSIS and the IEQ have four domains and a similar
number of items (24 and 27, respectively). The EDSIS domains
emphasise patient symptoms (nutrition, guilt, dysregulated beha-
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