Abstract The Caregiver Reaction Assessment Tool (CRAT) is a multidimensional instrument designed to measure caregiver’s experience while caring for elderly people with chronic illnesses in western countries. It is important to quantify the CRAT in traditional Thai society using cross-cultural translation and validate the instrument in measuring Thai informal caregivers who are providing care for elderly people. This study involved the cross-cultural translation process of the scale into Thai and evaluation of its psychometric properties with 354 caregivers of dependent elderly persons in Northern Thailand. Data were collected via paper-pencil surveys between October 2021 and March 2022, also caregivers completed a demographic form. The forward–backward translation, followed by exploratory factor analysis. The content validity index was high (I-CVI range from 0.83-1.00 and S-CVI = 0.90). Three items in the CRAT-Thai version were deleted, the other 21 items appeared to have a similar structure as the original version with five essential subscales: impact on schedule, lack of family support, caregiver’s esteem, impact on finances, and impact on health, explained 62.77% of the variation with all factors loading greater than .40. The internal consistency reliabilities for the items belonging to each subscale were, respectively: 0.85, 0.83, 0.81, 0.81, and 0.83. The Thai version of CRAT presents good evidence of reliability and validity based on internal structure. The further testing with Thai informal caregivers in different region should be made before using in all clinical setting.

Keywords: Dependent elderly persons, Caregivers, Psychometric testing, Caregiving reaction

Funding: This study was supported by CMU Junior Fellowship Program 2021.

Citation: Thana, K., Kamp, K.J., and Chintanawat, R. 2022. Psychometric properties of the Thai version of caregiver reaction assessment tool among caregivers who providing care for dependent elderly persons. CMUJ. Nat. Sci. 21(4): e2022058.

INTRODUCTION

With advances in healthcare systems and medical technology, people are now expected to live longer lives, into their sixties and beyond. By 2050, it is estimated that two billion of the world’s population will be aged 60 years and older (World Health Organization [WHO], 2020). All countries are demonstrating this shifting trend towards aging societies. Today, almost 12 million people in Thailand are considered senior citizens with an estimate of nearly 20 million people by 2050 (Department of Older Persons [DOP], 2019). Biological changes and aging process are commonplace and contribute to chronic illnesses and can become dependent on others for assistance (Warmoth et al., 2016).

Recent shifts in healthcare delivery and treatment as well as the numerous caregiving tasks for dependent elderly people have modified the responsibilities assigned to informal caregivers (Bielderman et al., 2015; Wicha et al., 2018). Informal caregivers are family members who providing unpaid care or help their elder relatives with Activities of Daily Living (ADLs, such as bathing, eating, toileting), Instrumental Activities of Daily Living (IADLs, such as shopping, driving, managing finances), and any medical/nursing tasks (Thana et al., 2021). With the Asian culture, there are social norm, ethical foundation, and cultural ideals (Filial piety) that underpinning for young family members of taking significant and long-lasting care of elderly relatives (Bedford and Yeh, 2019; Abusalehi et al., 2021) as well as enshrined in the caring philosophy of Thailand (Knodel et al., 2018). Asian adult children had persistent belief regrading respect and strong sacrificing for caring aged assisting older parents or relative at home (Knodel et al., 2018; Abusalehi et al., 2021).

Caring for aged family members was challenging and complex for informal caregiver. It can be rewarding and fulfilling for children’s roles. At the same time, caregiving can disrupt life patterns, consumes personal resources, and may be distressing. This can lead to a high level of caregiver burden which usually occurs when the increasing demands of the elderly care go beyond the caregiver’s ability and capacity (Rosas-Carrasco et al., 2014; Sabzwari et al., 2016). One such multidimensional instrument is the Caregiver Reaction Assessment Tool (CRAT) which was designed to measure both positive and negative aspect of caregiver’s experience while caring for elderly people with chronic physical impairment, Alzheimer’s patients, and cancer patients in the United States (Given et al., 1992). The CRAT is a relatively short instrument, including 24-items, which measures both positive and negative reactions to caregiving. The CRAT was refining to measure the multidimensional burden across different culture, and applying rigorous psychometric evaluation techniques (Stommel et al., 1992; Nijboer et al., 1999). This makes the CRAT a particularly suitable tool for use among informal caregivers who provide care for dependent elderly people. Furthermore, the CRAT has been widely used in different countries including Netherlands (Nijboer et al., 1999), Spain (Alvira et al., 2020), Turkey (Aşkın et al., 2020), South Korea (Yang et al., 2013), Japan (Misawa et al., 2009), China (Ge et al., 2011), Indonesia (Kristanti et al., 2019), and Singapore (Malhotra et al., 2012). The vast use of the CRAT has provided a wealth of information on caregiver burden and revealed satisfactory parameters of validity and reliability across cultures. The previous studies provide adequate evidence of the CRATs multicultural equivalence and encourages the implementation of its cross-cultural adaptation to Thailand.

This study aimed to 1) translate the CRAT based on the cross-cultural procedure, and 2) conduct psychometric testing of the CRAT-Thai version with informal caregivers of Thai dependent older adults.

MATERIALS AND METHODS

Participant and setting

A total of 384 informal caregivers were taken part in this study, of whom 30 were involved in the preliminary testing. This study was conducted from October 2021 and March 2022 in Chiang Mai province, Thailand. Proportionate stratified random sampling was used to achieve a representative caregiver. If the stratification is used, sampling error could decrease, power increases, and reduce the data collection time, (Gray et al., 2017. The number of participants was calculated using the number of CRAT parameters, the original CRAT parameters was 63. With the criterion of a 5:1 ratio, 315 was the minimum required number of participants for psychometric testing (Nunnally, 1978).

Participants were a family caregivers of dependent elderly people who were recruited from community settings. Inclusion criteria was: 1) being 18 years or older; 2) able to speak and understand Thai; 3) able to hear normal conversation; 4) cognitively oriented to person, place, and time (determined via researcher and/or research coordinator using Thai version of the Short Portable Mental Status Questionnaire [SPMSQ], SPMSQ score ≥ 8. The SPMSQ was developed by Pfeiffer in 1975 and then translated into Thai language by Intarasombat in 1996); 5) involved in a caregiving role for at least 6 months and spending at least 2 hours per day in the caregiving role, and 6) willing to participate in the study. Exclusion criteria were as follows: (1) having mental illness; (2) having an employment relationship with the patients.

Translation process of CRAT

After permission was obtained from the CRAT developers to translate the original tool into Thai language, the translation was performed using 5 steps of cross-cultural translation (Beaton et al., 2007). First, the CRAT was translated into Thai by two Thai native-speaking persons, a nurse who is experienced in gerontological and transcultural nursing and a linguistic professor who is proficient in second language acquisition. Second, the principal investigator (PI) resolved differences and synthesized the two CRAT Thai versions into a single version (draft of CRAT-Thai version). Third, the draft of CRAT-Thai version was back translated by two different translators. Fourth, an expert committee reviewed the CRAT-Thai back-translated English version to the original CRAT instrument for its compared and adaptation. Also, the back-translated English version with proofreading has been submitted to CRAT original developer for semantic, idiomatic, and conceptual equivalencies. Finally, the CRAT-Thai version was preliminary tested by 30 informal caregivers of dependent elderly persons in the Chiangmai, Thailand.

Cultural adaptation of the CRAT

Considering different cultural backgrounds in Thailand and the United States, appropriate changes were made through an expert panel approach. The CART-Thai version was reviewed by a panel of experts comprising two gerontologists, two gerontological advanced practitioner nurses, and two gerontological professors. They made comments on the relevance and clarity of each item of the tool using the 4-point Likert scales correspondingly: 1 = not relevant, 2 = a little relevant, 3 = relevant, 4 = highly relevant and 1 = very unclear needs full revisions, 2 = unclear and needs a bit of revisions, 3 = clear but needs only minor revisions, 4 = very clear not needs to be revised. The CVI was calculated at item level (I-CVI), with value more than 0.70 as recommended (Almanasreh et al., 2019). Consequently, 10 informal caregivers of elderly persons and 5 nursing staff were invited to participated in conducting structured interviews on the CRAT-Thai version items. They were asked whether each question was too difficult to understand or to answer and provided the suggestions for the appropriate words. The final CRAT-Thai version was established after completing all cross-cultural translation steps.

Study instruments

General information questionnaire

A caregiver socio-demographic characteristics questionnaire was used to collect information about age, sex, caregiver relationship (spouse/partner, children/stepchildren, relatives, friend or other), marital status, education (high school or less, some college degree, bachelor’s degree, or more than 4-year degree), employment status (not employed, full-time, part-time, or others), household income, and chronic illnesses.

Caregiver reaction assessment tool (CRAT)

The original CRAT was comprised of 24 items (Given et al., 1992) that query both positive and negative reactions of family caregivers of patients with cancer, chronic physical impairment, or mental problems. Each of the 24 items are rated on a 5-point Likert scale, 1 (strongly agree) to 5 (strongly disagree). The items are grouped in five subscales:

        1) Caregiver’s esteem- seven items (1, 7, 9, 12, 17, 20, and 23) that measure the value or worth attributed to caregiving because of the experience being rewarding or causing resentment.

        2) Lack of family support- five items (item number 2, 6, 13, 16, and 22) that assess the caregiver’s perception of being left with most of the caregiving responsibility or of family members working together.

        3) Impact on finances- three items (item number 3, 21, and 24) that evaluate the adequacy, difficulty, and strain of finances on the caregiver and family.

        4) Impact on schedule- five items (item number 4, 8, 11, 14, and 18) that measure the extent to which caregiving interrupts or interferes with the caregiver’s regular activities.

        5) Impact on health- four items (item number 5, 10, 15, and 19) that assess the caregiver’s capability to provide care and health in relation to caregiving.

Items 3, 7, 13, 15, and 19 were reverse scored. The CRAT measures the impact of providing care at the subscale level, with no overall summative score (Given et al., 1992). Average scores were computed across items within each subscale, so that subscale scores ranged from 1 to 5 with higher scores reflecting greater caregiver burden in that subscale. Four of the CRAT subscales were constructed in such a way that higher numbers indicated higher levels of burden, while the caregiver self-esteem subscale was constructed in the opposite manner: a lower number indicated a higher burden.

Short Portable Mental Status Questionnaire (SPMSQ)

The questionnaire comprised 10 questions that extend to questions to screen the presence of cognitive disorders and assess about the individual’s cognitive function, including time and place orientation, memory, and recent information. The questionnaire is scored from 0 to 10 based on sum of the subjects’ incorrect answers and then a person was placed in a cognitive disorder (Malhotra et al., 2013; Pfeiffer, 1975) category as follows: severe cognitive disorder (0 -2 correct answers), moderate cognitive disorder (3 -4 correct answers), mild cognitive disorder (5 -7 correct answers), and healthy (8 -10 correct answers).

Data collection

The research coordinators explained the purpose of the study and obtained informed consent. After obtaining permission, the research coordinator collected the data from caregivers using paper-pencil questionnaires. The survey participants and answers remained anonymous. The safety and health of study team and participants was our primary concern during the Coronavirus disease (COVID-19) pandemic. Throughout the collection time, researcher/research coordinator and participants were required to 1) wear a surgical facemask, 2) stay 6 feet apart, and 3) perform hand hygiene using hand sanitizer or hand washing with soap and water.

Ethical considerations

This study was approved by the Faculty of Nursing, Chiang Mai University Ethic Committee Review Board (No. 2564-EXP024). All caregivers who met the inclusion criteria were given a detailed explanation about the purposes, methodology, and the time requirement for the study. Caregivers were informed that participation in this study is voluntary, so they could refuse to participate and withdraw from the study at any time without negative effects or repercussion. The caregivers were reassured that their responses were kept confidential, and that data were analyzed and reported anonymously, according to the rules of good clinical practice and the Declaration of Helsinki.

Data analysis

The study data were analyzed using SPSS version 22.0. Descriptive statistics (frequencies, percentages, means, and standard deviations) were used to describe caregivers’ characteristics. Content validity was assessed by six experts using a four-point rating scale: 1 = not relevant, 2 = somewhat relevant, 3 = quite relevant, 4 = highly relevant. The scale content validity index (S-CVI) was calculated as a mean of the item content validity index (I-CVI) for all items on the CRAT-Thai version. The I-CVI was calculated as the number of experts giving a rating of 3 or 4, divided by the number of experts. Content validity indices were rated as acceptable when I-CVI and S-CVI/Ave were respectively at least 0.80 (Polit and Beck, 2006). Face validity was evaluated by 10 informal caregivers and 5 nursing staff. Construct validity was tested by exploratory factor analysis (EFA) to identify the rational-empirical process of testing the psychological attributes of the measure. Measurement reliability was evaluated to ensure that the measure delivers consistent results, valued by Cronbach’s alpha coefficients. Kaiser-Meyer-Olkin and the Bartlett test were conducted to check sampling adequacy with eigenvalue > 1 (Costello and Osborne, 2005) with a principal component analysis and varimax rotation with factor loading ≥ 0. 4 and, convergent validity (Pearson correlation > 0.2; Streiner et al., 2015), reliability (Cronbach’s alpha coefficients ≥ .80; Boateng et al., 2018), and inter-item and item-total correlation (Pearson correlation > 0.2; Kline, 2015). Item analysis was performed to verify the homogeneity between the items (inter-item correlation) and between each item and the overall scale (item-total correlation).

RESULTS

Caregiver characteristics

Caregiver characteristics are shown in Table 1. The mean age of caregivers was 52.19 years (SD = 13.68, range = 18–85) and 76.60% were female. Educational attainment and monthly household income were high, with 59.0% reporting a high school or less and 45.2% receiving 30,000-59,999 THB a month (approximately 1,000-2,000 USD). Almost half of the participants (45.5%) had a mean of 1.53 (SD=0.76) chronic illnesses. The most common caregivers ’chronic illnesses were hypertension and diabetes mellitus.

Table 1. Caregivers’characteristics for analysis (n=354).

Preliminary testing

For the preliminary testing, 30 caregivers gave their ratings on the CRAT-Thai version. There were no missing values. The mean time to complete the CRAT-Thai version was 9.5 minutes. Caregivers reported that the instruction was simple and easy to understand (83.33%). Twenty caregivers reported difficulties in understanding the term “repay” in item 12 (66.67%). Twenty percent of caregivers found the meaning of questions number 7 was a negative sequence in Thai culture.

Content validity

The overall content validity of CRAT-Thai version was high. The CVI was completed by six Thai geriatric doctors and experts in geriatric nursing using a 1–4 grading scale (high scores = high levels of relevance and clarity) and was calculated by considering the ratio of grading score at three or four of all 24 items. The obtained score on each CRAT- Thai version item was rated than three which demonstrated agreement on relevance and clarity of that item (I-CVI range from 0.83-1.00 and S-CVI=0.90).

EFA with 5 subscales

Table 2 shows the psychometric properties testing results. The database was suitable for EFA based on the Kaiser-Meyer-Olkin (KMO) measure, which resulted in 0.85, and Bartlett’s sphericity test was statistically significant (P=0.001) and reflecting adequacy of the sample size. According to Kaiser’s rule, five factors with an eigenvalue greater than 1 were retained, the EFA supported a 5-factor model with a principal component analysis and varimax rotation solution and accounted for 62.77% of the total variance with factor loadings ranged from 0.611-0.901. The initial exploratory factor analysis (EFA) model had three conflicting items (item 4, 7, and 12) that loaded poorly. Item 4 (“My activities are centered around care for …”) loaded onto 2 factors: impact on schedule (0.386) and lack of family support (0.410), which reflects that this item is not unique and measures two particular subscales. Item 7 (“I resent having to take care of….”) loaded on impact on schedule subscale instead of on caregiver’s esteem. Next, item 12 (“I will never be able to do enough caregiving to repay …”) was not sufficient to load on any factor. Therefore, research team decided to remove items 4, 7, and 12 from subsequent analysis and then, the final CRAT-Thai version consisted of 21 items with five factors:

Table 2. Factor loading of CRAT-Thai component analysis after varimax rotation.

impact on schedule (6 items), lack of family support (5 items), caregiver’s esteem (5 items), impact on finances (3 items), and impact on health (2 items).

In addition, internal consistency reliability and item analysis was completed. The Cronbach alpha coefficient was obtained (Table 2) for each of five subscales: 0.85 for impact on schedule, 0.83 for lack of family support, 0.81 for caregiver’s esteem, 0.81 for impact on finances, and 0.83 impact on health. Outcomes from the item analysis showed that each question of the CRAT-Thai version had the acceptable inter-item correlation ranging from 0.533 (Item 9 - I sincerely want to take care of …..) to 0.717 (Item 21 - Taking care of ….. causes financial difficulties in my family)

DISCUSSION

In this study, the English CRAT was culturally adapted into a CRAT-Thai version using a cross-cultural translation process. During the translation of the English CRAT into Thai language, a few minor cultural discrepancies were encountered. Therefore, five items of CRAT have been modified accordingly to use words more applicable to the Thai cultural context. After cross-cultural adaptation, the pretesting of the CRAT-Thai version revealed the items were clearly understood and helpful. The CRAT-Thai version can be used for assessing both negative and positive aspect of caregiving within 10 minutes. Moreover, CRAT-Thai version has the same 5-subscale as the original English version with adequate internal consistency. Such cultural translation and adaptation, it also provides the opportunity to conduct the comparison studies between Asian countries using the same CRAT instrument.

CRAT-Thai version has psychometric testing regarding feasibility, validity, and reliability. The exploratory factorial analysis of the CRAT-Thai version supports the use of the 21 items with 5 subscales, the internal consistency reliability of the subscales was above the index level of 0.80 (Cronbach’s alpha on impact on schedule-0.85, lack of family support-0.83, caregiver’s esteem-0.81, impact on finances-0.81, and impact on health-0.83). Unfortunately, there are 3 issues on validity testing. First, item 12 (“I will never be able to do enough caregiving to repay …”) appeared to be problematic because it had poorly loaded and did not load in any of the subscales, which is in line with previous Japanese and Indonesia studies (Misawa et al., 2009; Kristanti et al., 2019). This issue can be explained with the influence of Asian culture discrepancies, it is the responsibility of the younger family members to respect and take care of elderly relatives (Abusalehi et al., 2021; Bedford and Yeh, 2019). From our own experiences in Thailand, we found the family takes significant and long-lasting care of older persons within extended families and enshrined in the caring philosophy of Thai tradition (Knodel et al., 2018).

Second, the problem of measuring uniqueness, item 4 (“My activities are centered around care for …”) loaded into both impact on schedule and lack of family support subscales. This issue can be interpreted that Asian caregivers providing care for older adults as full-time work and living in the same house. So, informal caregivers might need time to break or need someone for helping while caring for dependent older parents (Abusalehi et al., 2021; Bedford and Yeh, 2019; Knodel et al., 2018; Nijboer et al., 1999). With this reason, the subscale of both impact on schedule and lack of family support cannot be differentiated by item number 4 and then researchers decided to delete it out. Finally, item 7 (“I resent having to take care of….”) loaded on impact on caregiver schedule subscale instead of on caregiver’s esteem. The culture and language are connected and can be justified this problem and then, caregivers might perceive caring for aged persons interrupted their own time.

The strength of this study is that it evaluates a multidimensional assessment of caregiving reaction and/or caregiver burden accessible to Thai informal caregivers who are providing care for dependent older adults. The limitation in this study is that it was not compared to other caregiver tools and the effects of COVID-19 pandemic on caregiver burden are unclear. Further research is needed to assess the test-retest reliability and other construct validity such confirmatory factor analysis of the CRAT-Thai version with more numbers of caregivers.

CONCLUSION

This study was the first attempt to translate and validate the CRAT into Thai language. The results revealed the CRAT-Thai version presented good evidence of validity based on the internal structure, as well as a reliable instrument for evaluation of Thai informal caregivers who are providing care for dependent older adults. The CRAT-Thai version led to five subscales incorporating 21 items: impact on schedule, lack of family support, caregiver’s esteem, impact on finances, and impact on health. The further construct validity of testing with Thai informal caregivers in different region should be made before use in all practice setting for assessing positive and negative aspects of caregiving such caregiver burden and then provide support and assistance to caregivers.

ACKNOWLEDGMENTS

Authors would like to thank the dedicated participants in the study, this work would not have been possible without their participation.

AUTHOR CONTRIBUTIONS

Kanjana Thana designed, conducted the data, performed statistical analysis, and contributed to writing the manuscript. Kendra J. Kamp contributed to statistical analysis and writing the manuscript. Rojanee Chintanawat contributed to designed and writing the manuscript. All authors have read and approved the final manuscript.

CONFLICT OF INTEREST

The authors have declared that there is no conflict of interest.

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Chiang Mai University Journal of Natural Sciences [ISSN 16851994]

Chiang Mai University, Thailand.

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