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Validity, reliability, and feasibility of the German version of the Caregiver Reaction Assessment scale (G-CRA): a validation study

  • Astrid Stephan (a1), Herbert Mayer (a1) (a2), Anna Renom Guiteras (a1) and Gabriele Meyer (a1) (a3)



Instruments measuring caregiver reactions usually disregard positive aspects, and focus predominately on home care. The Caregiver Reaction Assessment (CRA) scale is an exception. Until now, no German version has been available. We translated the instrument to German (G-CRA) and evaluated its psychometric properties and feasibility.


Face-to-face interviews with 234 informal caregivers of persons with dementia were performed. Half of the persons with dementia (n = 118) had been recently admitted to institutional long-term care (iLTC); the remainder (n = 116) lived at home. Exploratory factor analysis (EFA) was performed. Subscales were inter-correlated and further correlated with the Zarit Burden Interview (ZBI), the General Health Questionnaire (GHQ-12), and the EuroQuol (EQ-5D). Internal consistency was measured (Cronbach's α), and interviewers (n = 9) appraised feasibility. The time needed to apply the scale was measured in 20 interviews.


The EFA yielded six factors (Kaiser criterion), but a scree plot supported the five dimensions of the original version that explained 56.2% of variance. Low-to-moderate subscales’ inter-correlation was revealed. Highest correlation (r = 0.5) was found between impact on health and impact on daily schedule, indicating slight overlap. Criterion validity was supported by reasonable correlations between subscales and ZBI and GHQ-12 (r = −0.21–0.71). Subscale impact on health was negatively correlated with the EQ-5D. The internal consistency was sufficient (α = 0.67 − 0.78). Interviewers judged the G-CRA to be appropriate. Completion took 6.50 min (median value).


Our results suggest that the G-CRA is sufficiently valid and internally reliable. The instrument is applicable in home care and iLTC as well as in the transitional phase.


Corresponding author

Correspondence should be addressed to: Astrid Stephan, School of Nursing Science, Faculty of Health, Witten/Herdecke University, Stockumer Straße 12, Witten 58453, Germany. Phone: +49-2302-926-321; Fax: +49-2302-926-318. Email:


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Bachner, Y. G., O’Rourke, N. and Carmel, S. (2007). Psychometric properties of a modified version of the Caregiver Reaction Assessment Scale measuring caregiving and post-caregiving reactions of caregivers of cancer patients. Journal of Palliative Care, 23, 8086.
Braun, M., Scholz, U., Hornung, R. and Martin, M. (2010). The burden of spousal caregiving: a preliminary psychometric evaluation of the German version of the Zarit burden interview. Aging and Mental Health, 14, 159167. doi:10.1080/13607860802459781.
Brazier, J., Jones, N. and Kind, P. (1993). Testing the validity of the Euroqol and comparing it with the SF-36 health survey questionnaire. Quality of Life Research, 2, 169180.
Brodaty, H. and Donkin, M. (2009). Family caregivers of people with dementia. Dialogues in Clinical Neuroscience, 11, 217228.
Costello, A. B. and Osborne, J. W. (2005). Best practices in exploratory factor analysis: four recommendations for getting the most from your analysis. Practical Assessment, Research & Evaluation, 10, 19.
Damiani, al. (2011). Patterns of long term care in 29 European countries: evidence from an exploratory study. BMC Health Service Research, 11, 316. doi:10.1186/1472-6963-11-316.
Deeken, J. F., Taylor, K. L., Mangan, P., Yabroff, K. R. and Ingham, J. M. (2003). Care for the caregivers: a review of self-report instruments developed to measure the burden, needs, and quality of life of informal caregivers. Journal of Pain and Symptom Management, 26, 922953. doi:10.1016/S0885-3924(03)00327-0.
DeVon, H. al. (2007). A psychometric toolbox for testing validity and reliability. Journal of Nursing Scholarship, 39, 155164. doi:10.1111/j.1547-5069.2007.00161.x.
Engels, al. (2005). Möglichkeiten und Grenzen selbständiger Lebensführung in privaten Haushalten (MuG III). München, Germany: Bundesministerium für Familie, Senioren, Frauen und Jugend (BMFSFJ).
Etters, L., Goodall, D. and Harrison, B. E. (2008). Caregiver burden among dementia patient caregivers: a review of the literature. Journal of the American Academy of Nurse Practitioners, 20, 423428. doi:10.1111/j.1745-7599.2008.00342.x.
Gaugler, J. E., Mittelman, M. S., Hepburn, K. and Newcomer, R. (2010). Clinically significant changes in burden and depression among dementia caregivers following nursing home admission. BMC Medicine, 8, 85. doi:10.1186/1741-7015-8-85.
Ge, al. (2011). Reliability and validity of the Chinese version of the caregiver reaction assessment. Psychiatry and Clinical Neurosciences, 65, 254263. doi:10.1111/j.1440-1819.2011.02200.x.
Given, C. W., Given, B., Stommel, M., Collins, C., King, S. and Franklin, S. (1992). The caregiver reaction assessment (CRA) for caregivers to persons with chronic physical and mental impairments. Research in Nursing & Health, 15, 271283.
Goldberg, D. al. (1997). The validity of two versions of the GHQ in the WHO study of mental illness in general health care. Psychological Medicine, 27, 191197.
Gräßel, E. and Leutbecher, M. (1993). Häusliche Pflege-Skala HPS zur Erfassung der Belastung bei betreuuenden oder pflegenden Personen. Ebersberg, Germany: VLESS-Verlag.
Grov, E. K., Fosså, S. D., Tønnessen, A. and Dahl, A. A. (2006). The caregiver reaction assessment: psychometrics, and temporal stability in primary caregivers of Norwegian cancer patients in late palliative phase. Psychooncology, 15, 517527.
Kraemer, H. C. (2006). Correlation coefficients in medical research: from product moment correlation to the odds ratio. Statistical Methods in Medical Research, 15, 525545. doi:10.1177/0962280206070650.
Misawa, al. (2009). Validity and reliability of the Japanese version of the Caregiver Reaction Assessment Scale (CRA-J) for community-dwelling cancer patients. American Journal of Hospice & Palliative Care, 26, 334340. doi:10.1177/1049909109338480.
Nijboer, C., Triemstra, M., Tempelaar, R., Sanderman, R. and van den Bos, G. A. (1999). Measuring both negative and positive reactions to giving care to cancer patients: psychometric qualities of the Caregiver Reaction Assessment (CRA). Social Science and Medicine, 48, 12591269.
Persson, C., Wennman-Larsen, A., Sundin, K. and Gustavsson, P. (2008). Assessing informal caregivers’ experiences: a qualitative and psychometric evaluation of the Caregiver Reaction Assessment Scale. European Journal of Cancer Care, 17, 189199. doi:10.1111/j.1365-2354.2007.00833.x.
Peterson, R. A. and Kim, Y. (2013). On the relationship between coefficient alpha and composite reliability. Journal of Applied Psychology, 98, 194198. doi:10.1037/a0030767.
Pfaff, H. (2013). Pflegestatistik 2011. Pflege im Rahmen der Pflegeversicherung. Deutschlandergebnisse. Wiesbanden, Germany: Statistisches Bundesamt.
Schoenmakers, B., Buntinx, F. and Delepeleire, J. (2010). Factors determining the impact of care-giving on caregivers of elderly patients with dementia. A systematic literature review. Maturitas, 66, 191200. doi:10.1016/j.maturitas.2010.02.009.
Swartz, K. (2013). Searching for a balance of responsibilities: OECD countries’ changing elderly assistance policies. Annual Review of Public Health. doi:10.1146/annurevpublhealth-031912-114505
van Exel, N. J., Brouwer, W. B., van den Berg, B., Koopmanschap, M. A. and van den Bos, G. A. (2004a). Instruments for assessing the burden of informal caregiving for stroke patients in clinical practice: a comparison of CSI, CRA, SCQ, and self-rated burden. Clinical Rehabilitation, 18, 203214.
van Exel, N. J., Brouwer, W. B., van den Berg, B., Koopmanschap, M. A. and van den Bos, G. A. (2004b). What really matters: an inquiry into the relative importance of dimensions of informal caregiver burden. Clinical Rehabilitation, 18, 683693. doi:10.1191/0269215504cr743oa.
Verbeek, al. (2012). A European study investigating patterns of transition from home care towards institutional dementia care: the protocol of a RightTimePlaceCare study. BMC Public Health, 12, 68. doi:10.1186/1471-2458-12-68.
Zank, S., Schacke, C. and Leipold, B. (2006). Berlin inventory of caregivers’ burden – dementia. Zeitschrift für Klinische Psychologie und Psychotherapie, 35, 296305.
Zarit, S. H. (2012). Positive aspects of caregiving: more than looking on the bright side. Aging and Mental Health, 16, 673674. doi:10.1080/13607863.2012.692768.
Zarit, S. H., Reever, K. E. and Bach-Peterson, J. (1980). Relatives of the impaired elderly: correlates of feelings of burden. Gerontologist, 20, 649655.


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Validity, reliability, and feasibility of the German version of the Caregiver Reaction Assessment scale (G-CRA): a validation study

  • Astrid Stephan (a1), Herbert Mayer (a1) (a2), Anna Renom Guiteras (a1) and Gabriele Meyer (a1) (a3)


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