Community Integration Questionnaire

The Community Integration Questionnaire (CIQ; Willer et al. 1993) was intended as a brief assessment of community integration or the degree to which an individual after a TBI is able to perform appropriate roles within the home and community. To achieve higher levels of reliability, the CIQ uses behavioural indicators of integration and does not include items focused on feelings or emotional status (Dijkers 1997; Willer et al. 1994). The CIQ was developed for inclusion in the National Institute on Disability and Rehabilitation Research TBI model systems National Data Base in the United States (Dijkers 1997).

The CIQ assesses handicap, which is viewed by the scale authors as the opposite of integration in three domains: home Integration (i.e. active participation in the operation of the home or household), social Integration (i.e. participation in social activities outside the home) and productivity (i.e. regular performance of work, school and/or volunteer activities) (Willer et al. 1993). The scale is comprised of 15 items in three corresponding subscales each of which has a different number of items and sub-scores (Sander et al. 1999; Willer et al. 1994). The Home Integration subscale consists of 5 items each scored on a scale from 0-2, where 2 represents the greatest degree of integration. The Social Integration subscale is comprised of 6 items rated in the same manner as Home Integration whereas the Productivity subscale consists of 4 questions with responses weighted to provide a total of 7 points. Scores from each of the subscales are summed to provide an overall CIQ score. The maximum possible score is 29, which reflects complete community integration (Hall  et al. 1996).

The CIQ may be completed individually, face-to-face, or through telephone interviews (Hall et al. 1996). If the individual with TBI is unable to complete the assessment, the questionnaire may be completed by proxy (Willer et al. 1994). There are two versions of the questionnaire available, one for completion by the person with TBI and one for completion by a suitable proxy (family member, close friend, significant other; Sander et al. 1999). The CIQ requires approximately 15 minutes to complete (Hall et al. 1996; Zhang et al. 2002).

Table: Characteristics of the Community Integration Questionnaire

Advantages. The CIQ has become one of the most widely used tools in the assessment of community integration for people who have experienced TBI. The scale was originally developed via an expert panel that included individuals with TBI, suggesting that items have face validity (Willer et al. 1994; Willer et al. 1993). The scale can be completed quickly and easily by most individuals with TBI or by an appropriate proxy. The scale focuses more on behaviour than emotional states, which promotes better agreement between patient and proxy ratings (Cusick et al. 2000; Dijkers 1997).

Limitations. While the CIQ was developed to assess handicap (as defined by WHO under the International Classification of Impairments, Disabilities and Handicaps) the CIQ does not appear to assess all of the domains included in the definition (Dijkers 1997). Under the current definitions provided by the International Classification of Functioning, Disability and Health (WHO 2001), CIQ items may reflect activities more than participation (Kuipers et al. 2004). The reduction of items from 47 to 15 based on factor analysis excluded items not loading onto one of the three predetermined factors that might have provided a more comprehensive assessment of handicap and/or participation. It should be noted that the factor analysis used to eliminate scale items was based on scale scores from an extremely small sample (n=49) of individuals with severe TBI (Dijkers 1997; Willer et al. 1993). Lequerica et al. (2013) discovered that the CIQ is most effective when used to assess Caucasians in comparison to Black and Hispanic populations.

The CIQ does not measure integration skills, the success of integration activities from the point of view of the individual with TBI, nor the feelings or meaning associated with integration activities (Willer et al. 1993; Zhang et al. 2002). What the CIQ measures appears to be somewhat inconsistent. Some items measure the frequency with which activities are performed, while others measure the assistance or supervision required in order to perform an activity (Dijkers 1997; Zhang et al. 2002). In addition, the CIQ social integration subscale does not relate to other measures of social integration in the expected way. The CIQ social integration subscale appears inconsistently related to the CHART social interaction subscale (Willer et al. 1993; Zhang et al. 2002) and only weakly related to the FIM social interaction item (Sander et al. 1999). It has been suggested that all three may be measuring slightly different constructs. The FIM examines appropriateness of interaction while CHART assesses the size and composition of social networks. The CIQ does not assess either of these aspects of social integration (Sander et al. 1999).

Age, gender and level of education have all been reported to have an effect on CIQ scores. Dijkers (1997) reviewed four studies that reported the effects of age and, generally it appeared as though scores for women indicated greater integration into the home, while male scores typically suggested more integration into the productivity domain. Kaplan (2001) demonstrated similar effects of gender around home integration in a sample of individuals with malignant brain tumours. It has been suggested that a lack of more traditional, male household tasks may account for some of the reported differences in home integration (Dijkers 1997). The CIQ separates the activities of running a household from other productive activity. Therefore, it may penalize individuals who were, and continue to be homemakers. It may also penalize those individuals with family members who have always shared in home-making activities (Kaplan 2001). It has been suggested that this bias could be ameliorated by conducting a retrospective, pre-morbid assessment to provide a basis for comparison (Sander et al. 1999).

In his 1997 review, Dijkers reported a tendency for younger age to be associated with greater integration on the CIQ. Kaplan (2001) reported that older age was significantly related to poorer community integration both for the total CIQ and for each subscale. In addition to age and gender, amount of education appears to have an effect on community integration as assessed by the CIQ. More education is associated with better integration in all three dimensions (Heinemann & Whiteneck 1995; Kaplan 2001). Gender roles, age and education differences all impact the CIQ differently. These differences need to be reflected in the scale through the development of age-appropriate norms stratified by education, gender and marital status (Dijkers 1997; Kaplan 2001; Sander et al. 1999).

In an assessment of the factor structure and validity of the CIQ, Sander et al. (1999) identified two items that appeared problematic. It was recommended that the childcare item and the frequency of shopping item both be removed. The childcare item is frequently not applicable and appears to penalize people who have no children in the home while the shopping item loaded significantly on two of the three identified factors and did not contribute any unique information to the sale (Sander et al. 1999). 

 

Summary-Community Integration Questionnaire

Interpretability: The CIQ is widely used. However, no norms are currently available. There is no basis for determining that an individual’s level of integration on the CIQ is or is not normal (Dijkers 1997).

Acceptability: The scale is short and simple and represents little patient burden. It has been used successfully with proxy respondents. 

Feasibility: No special training is required to administer the CIQ. The scale is free, but should be requested from the scale author. It has been used in longitudinal studies to show change over time.

 

Table: Community Integration Questionnaire Evaluation Summary

Reliability

Validity

Responsiveness

Rigor

Results

Rigor

Results

Rigor

Results

Floor/ceiling

++

 

 

++(TR)

++(IO)

++(IC)

++

++

++

+ (p-values only)

+ (ceiling)

NOTE: +++=Excellent; ++=Adequate; +=Poor; N/A=insufficient information; TR=Test re-test; IC=Internal Consistency; IO=Interobserver; Varied (re. floor/ceiling effects; mixed results).