Original Article

Adaptation and Psychometric Testing of the Turkish Caregiving Competence Scale


  • Yasemin DEMİR AVCI
  • Sebahat GÖZÜM

Received Date: 06.02.2020 Accepted Date: 02.12.2020 Bezmialem Science 2022;10(1):81-87


This study aimed to adapt the Turkish version and assess the cultural and psychometric properties of the Caregiving Competence Scale (CCS).


CCS-Turkish form (CCS-TR) was tested in a sample of 337 family caregivers of patients who had a stroke. The explanatory and confirmatory factor analyses were carried out for construct validity. The item-total score correlations, Cronbach’s Alpha value, and split-half test were calculated for reliability. The score on the scale was 4-16 points.


The mean age of the caregivers was found to be 47.48 ± 14.52 years, whereas the mean age of patients who had a stroke was 70.34±12.04 years. According to expert opinion, the content validity index score of the scale was 0.83. The result of the confirmatory factor analysis revealed that the single-factor structure revealed a good fit. The Cronbach’s Alpha value was 0.83, whereas the split-half reliability value was r: 0.82. The total score of the scale was determined as 11.5±1.74.


This study revealed high validity and reliability values of the CCS-TR, which suggests that the scale can be safely used. The presence of CCS in different languages is an advantage for conducting comparative studies.

Keywords: Caregiving competence, caregiver, validity, and reliability, Turkish


The members of a family undertake the primary responsibility for long-term care of the individuals having a stroke. The family members undertaking the caregiving responsibility during the hospitalization period also continue to contribute to complex caregiving processes (1). Home-based healthcare services have rapidly developed in Turkey in recent years. Additionally, procedures, such as changing the catheter or wound care, may be performed in a home environment  (2). However, the care is dominantly provided by the families; therefore, families should be competent for caregiving. Financial support that is given by the state to the family members and the provision of some of the materials that are necessary for the patient may contribute to the competency of caregivers even if insufficient.

Fulfilling the care required for individuals who are dependent on daily life activities due to stroke is a long and difficult process. Incidents that are suddenly and unexpectedly experienced, like stroke, are difficult to be adopted by patients and caregivers (3). The caregivers trying to adopt caregiving state to the individual who had a stroke experience intense stress between their responsibilities and daily life activities. Within this context, acquiring the caregiving competency for the family or informal caregivers and acceleration, as well as support for process adaptation, are very critical issues (4). The researchers have stated that the negative experiences and caregiving burden on the family members undertaking the primary responsibility for caregiving to the bedbound individuals may be decreased by support and consultancy (5,6). Caregiving competency should be evaluated to determine the training requirements of individuals undertaking the caregiving responsibility (3). Preparation of training events is considered to be provided as a result of caregivers’ assessment in a planned manner and through the effective requirements to resolve the problems and meet the requirements (7). Family member preparations for the caregiving process and gaining the required skills and competencies are important for effective process management (4,7).

Valid, reliable, and feasible measurement tools are needed to determine the competency of the family or informal caregivers in patient safety and care surveillance. Scholten et al. (4) has noted that 96 measurement tools were used to evaluate the caregivers, and the number of the items in such tools varied between 4 and 37. Few measurement tools were found to measure the competency of the family caregiver in Turkey (8-10). Various measurement tools that assess the caregivers are reported in the literature; however, the Caregiving Competence scale (CCS) has been used in many studies since it included four items, with a single dimension that is easy to understand, and available in three different languages. Availability of CCS in English (11), Swedish (12), and Chinese (13) versions ease the process of international comparison.

The caregiver’s feeling of self-competent affects his/her behavior toward the patient. The CCS developed by Pearlin et al. (11) was used in many studies to evaluate caregiver competency. The CCA was used to measure the levels of caregiving competence perceived by caregivers of patient groups, such as patients with stroke, Alzheimer’s, cancer, and dementia, in the literature (14-17).

A study that measures the competency of caregivers applied 6 weeks and 90 min of group training to the caregivers of patients with Alzheimer’s. The study revealed an increased competency level of the caregivers and possibly educational and group discussions on various issues that are found difficult by the caregivers (14). Another study stated that psychoeducation that is given to caregivers increased their competency level and problem-solving abilities (15). A study conducted by Quinn et al. (16) with caregivers of patients with dementia revealed that the competency level of the caregivers was low and found a relationship between life quality and satisfaction and caregiver competency.

This study aimed to adapt the Turkish version and assess the cultural and psychometric properties of CCS, as well as assess its compatibility with the Turkish culture and compare it with the translated versions in other languages.



This study used a methodological design. The universe of the present methodological research consists of all caregivers that refer to neurology clinic and stroke polyclinic of a university hospital between December 1, 2017, and February 10, 2018. The sample included 377 caregivers who met the inclusion criteria. In the literature, different opinions are reported on sample size related to scale studies, wherein 20 participants are recommended per item; however, the number of adequate sample size is expressed as “50: very poor, 100: poor, 200: fair, 300: good, 500: very good, and 1000: excellent” to perform factor analysis (18). Therefore, the sample size of 400 was targeted and the data of 377 participants (participant rate of 94%) who agree to participate were evaluated. Additionally, Kaiser-Meyer Olkin and Bartletts’ test indicated that our sample was enough for factor analysis.

Inclusion criteria were as follows:

• To be the primary caregiver of patients who had a stroke

• Dependency level of the patient at 2, 3, and 4 according to Modified Rankin scale (19,20)

• Literate caregiver

• Having no communication problem

• Contribution request of the caregiver to the study

Data Collection tools

CCS-Turkish Form (CCS-TR)

Pearlin et al. (11) developed the CCS consisting of four questions. The Likert-type scale was structured as “not sufficient at all” as 1, “slightly sufficient” as 2, “sufficient” as 3, and “very sufficient” as 4. The lowest score was 4 and the highest score was 16. An increased score on the scale meant an increased caregiving competency (11).

Furthermore, some caregiver and patient characteristics, such as age, gender, and marital status, as well as the income level of the family, kinship with the patient, gender, age of the patient, stroke type, dependency grade, and other chronic diseases, were examined.

Data Collection Method

Written consent of the caregivers was obtained to conduct the research. Furthermore, the questionnaires were completed through personal interviews with the caregivers in the neurology clinic and stroke polyclinic of the university hospital. The data were collected in the stroke polyclinic for 1 week and in the neurology clinic when the researcher was available. The questionnaire was filled through face-to-face interviews of caregivers who met the inclusion criteria by the researcher. The data were collected in an available separate room.

The Adaptation of the Scale and Its Translation

The translation process included a translation panel, opinions of experts, re-translation, and pilot implementation. The independent professional translation was performed by 2 independent translators, 1 neurologist, 2 nurses, and 1 academician who understands and speaks both languages (Turkish-English). The ten experts’ opinion stage of the scale was performed by eight professors from the department of nursing, a nurse from the neurology clinic, and an instructor from the Department of Foreign Languages. Re-translation was performed by an instructor from Foreign Languages Department through expert opinions.

CCS-TR was tried as a pilot implementation for comprehensibility and caregivers of 30 patients who had a stroke. Minor revisions were made to avoid any changes in the meaning after the preliminary evaluation. The minor revision was reported to one of the authors, Sample S. J., who developed the CCS via e-mail (e-mail date: 22.03.2018), and his consent was obtained.

Data Analysis

The data were analyzed using the Statistical Package for the Social Sciences (SPSS) (Statistical Package for Social Science) 23.0 program. A normality test was performed before statistical analysis. Cronbach Alpha and Split Half Reliability were used for validity and reliability; Kaiser-Meyer Olkin (KMO) and Barlett test for explanatory factor analysis was done in the SPSS program. The Linear structural relations 8.71 package program was used for confirmatory factor analysis. The item-total score correlation and Cronbach Alpha and Split Half Reliability were performed for the reliability of the scale. The test-re-test method was not appropriate for the scale. Therefore, two half reliability method was implemented. The Independent Samples t-test in binary groups was used to analyze the demographic features in CCS-TR scores. The one-way analysis of variance was used in more than two groups.


Consent was obtained from the scale developer before initiating the research. Written consents from the Ethical Committee of the University Hospital (01/06/2017-10/07) and of the hospital, where the research was carried out, were obtained. Informed consent was signed by the caregivers who volunteered to participate in the study.


The mean age of the caregivers was 47.48±14.52 years, whereas in patients who have stroke was 70.34±12.04 years. Among the caregivers, 75.7% (n=255) were female and 60.8% (n=205) were male. Married caregivers consisted of 83.1% of all participants; 49.8% (n=168) of them were elementary school graduates and had lower educational levels; and 25.2% (n=85) were unemployed. Almost half of the patients were parents of the caregivers (47.8%, n=308). The majority of patients who had a stroke were diagnosed with ischemic stroke (91.4%, n = 308). The most common concomitant chronic disease of patients who had a stroke was hypertension by 40.4% (n=136) (Table 1).

Content Validity

Each item was evaluated by 10 specialists as “not adequate” as 1, “slightly adequate” as 2, “very adequate” as 3, and “very adequate” as 4. Content Validity index (CVI) of the scale was 0.83. CVI values of the items were determined as 0.07, 0.06, 0.08, and 0.09, respectively.

Construct Validity

The exploratory factor analysis revealed that 66.675% variance of the scale is at a single dimension. Variance analysis KMO of 0.81 indicated that the sample size was very good and the significance of the Bartlett test showed that the data was adequate for factor analysis (c2=491.133; p=0.000). No rotation was performed since the scale had a single-factor structure (Figure 1). Excellent compliance of the single-factor structure was found as a result of confirmatory factor analysis [root mean square error of approximation (RMSEA) =0.00, normed fit index =0.00, comparative fit index (CFI) =0.00, incremental fit index =0.00, relative fit index =0.99, goodness of fit index (GFI) =0.00, and adjusted goodness of fit index =0.99] (Table 2, Figure 2).


Corrected item-total correlation values of the scale were 0.620, 0.698, 0.666, and 0.659 (Table 3). The Cronbach Alpha value was 0.83. The value of the two-half reliability was r=0.82.

The distribution of the effect of the descriptive characteristics of caregivers on the average score of the care competency scale was presented and revealed that previous experience of caregiving and level of dependence of the patient affected caregiver competency (p<0.05) (Table 4).


CCS was adapted into the Turkish version linguistically and culturally appropriate. The validity of the content was performed in the compliance among specialist opinions after the translation process at the language adaptation phase of the measurement tool (19). The grade of scale comprehensibility and the measured qualifications between the specialists were similar to the Chinese version (12) (CVI =0.83). Scope validity values of the four items for I-CVI were 0.07 and 0.09 and were similar to the Chinese version values (13).

The Adaptation of the CCS was developed by Pearlin et al. (11) and adopted into English as well as Chinese and Swedish and into Turkish was found to be valid and reliable. The majority of participants were female, elementary school graduates, and unemployed. Such profile was found to be similar to the profile of females, with low educational level, and unemployed in other countries (10,13). The validity and reliability of CCS in a group indicated that it can be used in a wider population. CCS was performed on caregivers of 337 patients who had a stroke, whereas the English version was implemented to caregivers of 326 patients with dementia by Perlin et al. (11) and Swedish and Chinese versions were performed on caregivers of 124 patients with cancer (12) and 118 patients who had a stroke (20), respectively. Multi-centered studies and comparative analyses may be carried out by confirming the validity and reliability of CCS.

The caregivers expressed the caregiving competency perceived in the scale. Two scoring types were found in the literature. Moreover, the original scale score was observed to vary between 4 and 16, and 0 and 12 in other scoring types. The average score of the CCS-TR was 11.5, Cheng et al. (20) at 12.5, and Cheng et al. (20) found the score as 12.3. Chan et al. (21) found such score as 11.4, whereas Henriksson et al. (12) detected a score of 6 with the lowest score compared with other studies. The reason was that scoring was performed according to 0 and 12.

Confirmatory factor analysis presented excellent compliance. Therefore, any modification is unnecessary (Figure 2). Factor analysis was similar to the study by Henriksson  et al. (12). Despite the cultural difference, similar results have indicated that the problems of the caregivers are similar. The result has revealed that the need is universal and the perceived caregiving competence should be improved.

The situation to be considered in the evaluation of confirmatory factor analysis is the ratio of the chi-square value to the degree of freedom. Civelek (23) considers this ratio to be below 3 as a sign of perfect harmony. This value was found 0.61 in CCS-TR, which shows a perfect fit. The RMSEA value of the scales with confirmatory factor analysis should be close to or equal to 0, whereas the GFI and CFI values close to 1 increased the level of compliance. The CFI value of CCS-TR was 0.00, the GFI was 0.00, and the RMSEA was 0.00. Considering all these criteria, the adaptation study was successful according to the exploratory and confirmatory factor analyzes results of the scale (Table 2). This situation was similar to the original CCS (11) and Chinese (12) and Swedish (13) language versions.

Factor loads of items under a single-factor ranged between 0.785 and 0.842. Concurrently, the breaking point was examined on the screen plot, and the scale showed a single-factor structure from the breaking point (Figure 1). CCS-TR explained 66.675% of the variance of the single-factor structure. Orçun (24) stated the requirements of the variance that was explained in the measuring scale at 52% and over.

The Cronbach Alpha was frequently used to determine internal consistency in scale development studies. The Cronbach Alpha level varies between 0 and 1. The lowest score should be 0.70 and over in scale studies (25). The present study revealed a Cronbach Alpha of 0.83, which is sufficient. The Cronbach Alpha level in the original scale was 0.74, whereas Henriksson  et al. (12) revealed it at 0.86 and Cheng et al. (13) at 0.81. The reliability values of the scale were found close to each other. The Cronbach Alpha value of the present study was determined as higher than the original value, due to the performance of the study in 1990. The healthcare system improvement within the years and increased options associated with the care and educational levels of the individuals may be related to the increased knowledge on competence concept by the caregivers.

Study Limitations

Our study revealed that the caregivers with previous experience of care in moderate disability of patients who had stroke increased the caregiver competency (Table 4). Contrarily, the moderate dependence of patients increased the caregiver competency. Another study that was conducted with caregivers of patients who had a stroke revealed that the ability of caregivers to deal with problems affected their competency (15). The study of Llanque et al. (14) noted that stress and fun affected the caregiving competency. The literature revealed that efforts made for caregivers of patient groups, such as stroke, Alzheimer, and dementia, increased the caregiver competency (14-16), whereas no increase in the caregiver competency was found in a randomized controlled study, where psychoeducation was applied to caregivers of patients with cancer in palliative care (17). This result could be due to the high mortality in patients with cancer and the duration and content of these efforts.


The validity and reliability values of the CCS-TR were similar to the English, Swedish, and Chinese versions. The validity and reliability values of the CCS-TR were high, which revealed its safety. The presence of CCS in different languages provided an advantage for conducting comparative studies, whereas the fact that the scale was a short and easy tool provided an advantage for its use in the field by healthcare professionals.


Ethics Committee Approval: Association Declaration of Helsinki “Ethical Principles for Medical Research Involving Human Subjects,” (protocol no: 10/07, date: 01.06.2017).

Informed Consent: The caregivers were informed about the study and their written consents were obtained.

Peer-review: Externally peer reviewed.

Authorship Contributions

Concept: Y.D.A., S.G., Design: Y.D.A., S.G., Data Collection or Processing: Y.D.A., Analysis or Interpretation: Y.D.A., S.G., Literature Search: Y.D.A., Writing: Y.D.A., S.G.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.

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