Dijkers , PhD, Mount Sinai School of Medicine at
Citation Dijkers, M. (2000).
The Community Integration Questionnaire. The Center for
Outcome Measurement in Brain Injury. http://www.tbims.org/
combi/ciq ( accessed
This citation is for the COMBI web material. Dr. Dijkers is
not the scale author for the CIQ.
(re)integration refers to being in (returning to) the mainstream
of family and community life, by persons with impairments and disabilities
due to injury, chronic illness, or old age. Other terms for the
same or similar phenomena include: independent living; normalization;
deinstitutionalization; mainstreaming;lack of handicap; social participation.
Community integration may be measured by collecting information
including instrumental activities of daily living (IADLs), hobbies
and productive activity in household, work, school, and community;
kin, and work relationships;
roles in the marital dyad, family and society at large;
sometimes physical independence, community mobility, and economic
Community Integration Questionnaire (CIQ) was intended to be a brief,
reliable measure of an individual's level of integration into the
home and community. It is important to note that this questionnaire
represents a finite set of indicators of community integration,
and as such does not encompass all possible indicators of integration.
analysis of the clinimetric properties of the CIQ is contained in
the review paper by Dijkers in the Journal of Head Trauma Rehabilitation,
1997. (See references). The following
is a short summary, supplemented by information from research published
after that date:
Results of reliability studies have been mixed. Based on the (Pearson)
correlations reported in the earliest study, the interrater reliability
of the CIQ appears in the "acceptable" range (Willer et al., 1993).
However, the intraclass correlation coefficient (ICC), a more appropriate
measure, resulted in much lower numbers, according to a later investigation
(Tepper et al., 1996), especially for the Home (H) dimension. The
most recent research (Sander et al., 1997) also suggests that in
home integration there is the greatest discrepancy between reports
by subjects with TBI and those by their proxies. In the latter study,
the person with TBI tends to report higher values than the proxy
for all three components.
et al. also calculated kappa for the correspondence between person
with TBI and proxy reports on each of the 15 individual CIQ questions
Sander et al, 1997). Kappas ranged from .42 (shopping) to .94 (school).
While these figures are in the moderate or better range for kappa,
there was a tendency for patients to rate themselves as more integrated
on the Home and Productivity (P) items, and on three of the Social
Integration (S) items.
traditional cut-off point for acceptable internal consistency as
measured by coefficient alpha is .80. For the CIQ total, three out
of four studies (Willer, Linn & Allen, 1994, Willer, Ottenbacher
and Coad, 1994; Corrigan and Deming, 1995; Heinemann and Whiteneck,
1995) have reported levels that exceed this criterion. However,
the corresponding values for the S and P dimensions are much lower,
especially for the latter - quite likely due to the fact that alpha
is based on only two variables, which are very dissimilar from one
another: work/study/volunteering, and travel.
issues. Corrigan and Deming (1995) noted negatively skewed distributions
for the premorbid data for CIQ total, positive skews for H for all
four samples, negative skews for all samples for the S dimension,
and negative skew for P for the TBI-premorbid sample, but positive
skew for the three others. Various kurtosis (peakedness/flatness
of the distribution) problems were also noted. They recommended
that the P subscale not be used independently from its contribution
to the CIQ total score. Distribution problems that could not be
resolved completely by transformations of the CIQ scores were also
noted by Willer, Ottenbacher & Coad (1994). Non-parametric statistics
may need to be used in order to deal with potentially non-normal
et al. (1996) noted that about half of their subjects reached a
score equal to or greater than the mean of a control sample on the
H and S dimensions. (equivalent to the average value for the Willer,
Linn & Allen (1994) control sample) at one or two years post-injury.
On the P dimension, however, less than one quarter reached the controls'
average. The authors state that this limits the CIQ's usefulness.
However, they do not report what percentages reached the theoretical
maximum for each scale - the true measure of a ceiling effect.
No formal content or face validity studies of the CIQ have been
done, but it was developed utilizing a panel consisting of both
consumers and professionals with expertise in TBI outcome studies
subscales and total score have been found to have correlations with
subscales and total score on CHART (another measure of community
integration), impairment and disability, time since injury, and
subjective quality of life (Heinemann and Whiteneck, 1995). However,
two small studies reported results that contradicted these findings
(Burleigh et al., 1997; Smith et al., 1998). Most studies find negative
correlations between CIQ and subtotals (except sometimes H) and
age. Females tend to have higher CIQ scores for total, H and S than
males, but lower P scores.
The available research shows that the CIQ can validly distinguish
between persons with TBI and non-disabled controls (Corrigan and
Deming, 1995; Willer, Ottenbacher & Coad, 1994; Gordon et al.,
1999). With one exception, persons with TBI are less integrated
along all dimensions than controls. In a comparison between individuals
with mild TBI and normal controls, individuals with mild TBI scored
significantly lower on the productivity subscale (Paniak et al,
1999). There were no differences between these two groups in the
home and social integration subscales. In one study (Willer, Ottenbacher
& Coad, 1994), CIQ scores distinguished between three groups
of persons with TBI living in settings differentiated by supervision/support
level: independent in the community, in the community with some
(natural) support, and in an institution such as a nursing home,
rehabilitation facility, etc. Willer et al. (1999) reported gain
in CIQ (sub)scores for people with TBI receiving residential rehabilitation
services between the second and third anniversary of injury, while
a control group who received no or minimal home-based services did
not show a gain. In another study, at most a Evidence of changes
in CIQ (sub)scores over time are absent from the literature, with
one exception where a very small increase from the first to the
second anniversary of injury was reported for a group that in large
majority did not any more receive rehabilitation services (Hall
et al, 1996). Corrigan et al. (1998) on the other hand, found trends
toward improvement in all three subscales and total score in a cross-sectional
study covering anniversaries one through four.