International Journal of Nursing Studies 123 (2021) 104070

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Instruments to assess self-neglect among older adults: A systematic

review of measurement properties ✩
Min Qian, Yuexian Shi, Jinghong Lv, Mingming Yu∗
School of Nursing, Peking University, Beijing, P.R. China

article info abstract

Article history: Objective: To critically appraise, compare, and summarize the measurement properties of existing instru-
Received 19 April 2021 ments that assess self-neglect among older adults.
Received in revised form 18 August 2021
Methods: Eight electronic databases (PubMed, Scopus, Embase, CINAHL Plus with Full Text, Web of Sci-
Accepted 18 August 2021
ence, PsycINFO, China National Knowledge Infrastructure, and WanFang Data) were searched from their
inception to September 6, 2020. The methodological qualities of the included studies on measurement
Keywords:
properties were assessed by using the COnsensus-based Standards for selection of health Measure-
Instruments
Measurement properties ment INstruments (COSMIN) methodology for systematic reviews of Patient-Reported Outcome Measures
Self-neglect (PROMs).
Systematic review Results: Among the 1184 studies identified, 47 full-text studies were assessed further for their eligibil-
ities. A total of 8 studies were eventually included. The methodological quality of content validity for
relevance, comprehensiveness, and comprehensibility of all instruments in this review was doubtful or
inadequate. The methodological quality of structural validities in the majority of the studies were very
good, while the quality of hypothesis testing for construct validity was doubtful. The internal consistency
was assessed by calculating Cronbach’s alpha coefficient in all studies. Some measurement properties
(e.g., cross-cultural validity/measurement invariance, measurement error, and responsiveness) were not
assessed in the reviewed studies.
Conclusions: This systematic review provides a comprehensive overview of the measurement properties
of elder self-neglect instruments. Among the eight instruments identified, none of them demonstrate
better properties than any other. Future studies are suggested to use COSMIN methodology as guideline to
examine the measurement properties of the developed instruments. Instruments with rigid measurement
properties are urgently needed to assess self-neglect among older adults to provide the necessary and
valuable information on this particular phenomenon.
© 2021 Elsevier Ltd. All rights reserved.

What is already known What this paper adds

• Self-neglect is a common phenomenon and prominent public
problem in older adults.
• Self-neglect is associated with early mortality, increased read-
mission and hospitalization, suicidal ideations, and diverse
forms of elder abuse.
• Effort has been exerted to develop self-neglect instruments for
older adults. However, no rigorous evaluations and summaries
of measurement properties have been conducted to date.
• Eight instruments are available to assess self-neglect of older
adults. However, no evidence has been found regarding which
instrument is superior to others.
• Future studies should consider COSMIN methodology as instru-
ments development guideline. Moreover, the self-reported and
proxy-reported methods should be adopted in one instrument
to obtain the entire and accurate picture of self-neglect in older
adults.

✩ 1. Introduction
Register number: CRD42020218810
∗
Corresponding author.
E-mail addresses: qianmin2019@pku.edu.cn (M. Qian), lv@bjmu.edu.cn (J. Lv), Self-neglect, formerly called “Diogenes syndrome” (Clark et al.,
yumm@hsc.pku.edu.cn (M. Yu). 1975), “senile breakdown” (Macmillan and Shaw, 1966), and “senile

https://doi.org/10.1016/j.ijnurstu.2021.104070
0020-7489/© 2021 Elsevier Ltd. All rights reserved.
2 M. Qian, Y. Shi, J. Lv et al. / International Journal of Nursing Studies 123 (2021) 104070
squalor syndrome” (Kafetz and Cox, 1982), is a prominent problem
in older adults (Braye et al., 2011; Yu et al., 2020). The first em-
pirical study on self-neglect was conducted in 1966 in England,
and self-neglect was called “senile breakdown” (Macmillan and
Shaw, 1966) . In the late 1970s, the term “self-neglect” was gradu-
ally used in the medical and social literature (Roe, 1977; Reed and
Leonard, 1989). Self-neglect is treated as a subtype of elder abuse
in some states in the US (National Center on Elder Abuse Web-
site 2021). However, in Ireland, Australia, and the UK, self-neglect
is not included as a subtype of elder abuse. To date, there has
been no internationally accepted definition of self-neglect. Ac-
cording to the US National Center on Elder Abuse (NCEA), self-
neglect refers to “…the behavior of an elderly person that threat-
ens his/her own health and safety and generally manifests it-
self in an older person as a refusal or failure to provide him-
self/herself with adequate food, water, clothing, shelter, personal
hygiene, medication (when indicated), and safety precautions”
(National Center on Elder Abuse Website 2021).
The risk factors of elder self-neglect are poorly understood,
and previous studies have shown that it may be related to trau-
matic personal experiences, perceptions, and behaviors devel-
oped over a lifetime, such as separation and abandonment, par-
ticularly in childhood or adolescence (Lien et al., 2016). Never-
theless, multiple risk factors associated with elder self-neglect
have been identified, including depressive symptoms/depression
(Burnett et al., 2006; Yu et al., 2019), cognitive impairment
(Abrams et al., 2002; Dong et al., 2010; X. Dong, Simon,
Mosqueda et al., 2012; Dong and Simon, 2016;), male gender
(Dong et al., 2010, 2016), low income (Dong et al., 2012), older
age (Dong, 2016), living alone (Burnett et al., 2006; Lee and
Kim, 2014), and low level of physical function (Dong and Si-
mon, 2016). Self-neglect can result in negative health outcomes
among older adults, including early mortality, increased read-
mission and hospitalization, suicidal ideations, and diverse forms
of elder abuse (Dong et al., 2009, 2012; Dong et al., 2013,
2017).
According to a recent published systematic review of self-
neglect in older adults, the prevalence rates of elder self-neglect
range from 18.4% to 29.1% (Yu et al., 2020). Nevertheless, such
prevalence rates are likely underestimated and underreported
(May-Chahal and Antrobus, 2011) because of the absence of uni-
versally accepted standards for definition, assessment, and severity
measurement of self-neglect. In addition, self-neglect is occasion-
ally reported under the category of “elder abuse,” and such a phe-
nomenon also contributes to rate underestimation. Hence, instru-
ments to recognize and assess self-neglect for older adults have
been in urgent need, considering the large older population and
significant effects of self-neglect on the health outcomes of older
people.
Although multiple instruments have been developed and avail-
able for use as elder self-neglect measurement instruments, min-
imal information regarding their methodological quality can be
referred to. Accordingly, researchers and health professionals are
challenged to make a choice on which elder self-neglect in-
strument they should adopt. To the best of our knowledge,
no systematic review has been conducted, particularly on the
measurement properties of self-neglect instruments among older
adults. The primary aim of this systematic review was to iden-
tify current self-neglect instruments for older adults and to
evaluate their measurement properties based on the COSMIN
methodology for systematic reviews of PROMs (Mokkink et al.,
2018a,b; Prinsen et al., 2018; Terwee et al., 2018) . We are op-
timistic that our critical appraisal of the measurement prop-
erties of self-neglect instruments can provide useful and prac-
tical references for other researchers and health professionals
who are interested in the self-neglect phenomenon among older
adults.
2. Methods
2.1. Design
A systematic review of the measurement properties of self-
neglect instruments in older adults was conducted according to the
COSMIN methodology for systematic reviews of PROMs (Mokkink
et al., 2018a,b; Prinsen et al., 2018; Terwee et al., 2018). A proto-
col for this systematic review was registered in PROSPERO and the
register number is CRD42020218810.
2.2. Search strategy
A comprehensive literature search was conducted in six English
electronic databases, namely, PubMed, Scopus, Embase, CINAHL
Plus with Full Text, Web of Science, and PsycINFO; and two Chi-
nese databases including China National Knowledge Infrastruc-
ture (CNKI) and WanFang Data from their inception to Septem-
ber 6, 2020. The Medical Subject Headings (MeSH) terms and key-
words in the title or abstract were combined together with the
“OR” and “AND” Boolean operators when appropriate. These MeSH
terms and keywords were as follows: self-neglect, Diogenes syn-
drome, senile breakdown, social breakdown syndrome, Diogenes of
snipe, domestic squalor, squalor syndrome, messy house syndrome,
gross self-neglect, self-endangering behavior, surveys and question-
naires, survey, instrument, questionnaire, tool, scale, screen∗ , and
measure∗ . In addition, the reference lists of all retrieved papers
were further searched for potential studies. The detailed search
strategy as an example in the PubMed database is provided in sup-
plemental file 1.
2.3. Eligibility criteria
The eligible studies should meet the following criteria: (1) orig-
inal studies aiming to develop an instrument to measure self-
neglect of older adults aged 60 years or above (A minor modifica-
tion was made regarding the cutoff age of the older adults. In the
registered protocol, a cutoff age of 65 years was used. However,
the age of 60 years was adopted in the present review to include
as many as eligible studies.); (2) describing at least one measure-
ment properties of the self-neglect instruments (Mokkink et al.,
2010) and/or the scale validation process; and (3) full-text articles
published in Chinese or English (Authors of this review are native
Chinese speakers and inclusion of both English and Chinese studies
can expand the breadth of the review). Studies were excluded from
this review if they were conference proceedings, editorials, com-
mentaries, abstracts only, newsletters, research protocols, or letters.
2.4. Study selection
All records of eight databases were imported into the reference
management software program Endnote X 9.3.3. After the removal
of duplicates, two authors (QM &YM) independently reviewed the
titles and abstracts of the remaining records for relevance to the
review topic. Studies that potentially or completely met the inclu-
sion criteria were kept and their full-texts were retrieved. The two
authors assessed and screened the full texts to decide whether to
keep the records in the review. Discrepancies were discussed with
a third author (SY) to reach a consensus. The final included studies
were reviewed by all authors for agreement.
 M. Qian, Y. Shi, J. Lv et al. / International Journal of Nursing Studies 123 (2021) 104070
2.5. Data extraction
The following information of each included study was extracted
in two standardized information forms: (1) characteristics of the
included PROMs, such as item generation, target population, par-
ticipants, mode of administration (self-reported/proxy-reported),
number of items, response options, range of scores, original lan-
guage, and available translated version; and (2) results of stud-
ies on measurement properties, such as content validity, structural
validity, internal consistency, reliability, and hypothesis testing for
construct validity.
2.6. Methodological and measurement quality assessment
The methodological quality of the included studies was as-
sessed using the COSMIN Risk of Bias checklist (Mokkink et al.,
2018a). The COSMIN Risk of Bias checklist was initially developed
by the COSMIN steering committee to assess risk of bias of stud-
ies on measurement properties in systematic reviews of PROMs
(Mokkink et al., 2018a). The checklist has 10 boxes related to
instrument development (35 items), content validity (31 items),
structural validity (4 items), internal consistency (5 items), cross-
cultural validity/measurement invariance (4 items), reliability (8
items), measurement error (6 items), criterion validity (3 items),
hypothesis testing for construct validity (7 items), and responsive-
ness (13 items) (Mokkink et al., 2018a; Prinsen et al., 2018; Terwee
et al., 2018). All items are rated on the four-point rating scale in-
cluding very good (V), adequate (A), doubtful (D), or inadequate (I)
against the COSMIN methodology. The overall score of each box in
a measurement was judged based on the lowest rating within the
criterion called “the worst score counts” (Terwee et al., 2012).
The quality of measurement properties of each instrument
was rated by the updated criteria for good measurement proper-
ties (Prinsen et al., 2018). According to the COSMIN methodology
(Mokkink et al., 2018a,b; Prinsen et al., 2018; Terwee et al., 2018),
if the content validity (step 5) is rated as insufficient, authors can
skip steps 6–8 and directly draw a recommendation for a PROM
in step 9. However, the COSMIN methodology (Mokkink et al.,
2018a,b; Prinsen et al., 2018; Terwee et al., 2018) was published
in 2018, while 7 out of 8 scales in this review were published be-
fore 2018 or in 2018. Researchers of these included studies may not
know this COSMIN methodology. By referring to other published
systematic reviews of measurement properties (Charette et al.,
2020; Gentizon et al., 2021), group discussion, and expert consul-
tations, we finally decided to evaluate the measurement proper-
ties of a PROM step by step according to the COSMIN methodology
(Mokkink et al., 2018a,b; Prinsen et al., 2018; Terwee et al., 2018).
The measurement properties of a PROM can be rated as sufficient
(+), insufficient (–), or indeterminate (?) against the updated crite-
ria (Prinsen et al., 2018).
3. Results
3.1. Studies identification
A total of 1184 records were originally identified through sys-
tematic database searching, with 133 in Embase, 279 in Scopus, 118
in PubMed, 253 in Web of Science, 217 in PsycINFO, 121 in CINAHL
Plus with Full Text, 41 in CNKI, and 22 in WanFang Data. After
the removal of duplicates, title/abstract screening, full-text reviews,
and additional searches, eight studies were eventually included in
the systematic review. The study search and selection process were
presented in Fig. 1.
3
3.2. Characteristics of the included studies
Eight instruments that were specifically developed or translated
to assess self-neglect for older adults were identified: Elder Self-
Neglect Assessment (ESNA) (Iris et al., 2014), Elder Self-Neglect
Questionnaire (ESNQ) (Cai, 2015), Scale of the Elderly Self-Neglect
(Rural) (SESNr) (Zhao, 2017), Self-Neglect-37 (SN-37) (Day and Mc-
Carthy, 2016), Istanbul Medical School Elder Self-Neglect Question-
naire (IMSelf-neglect) (İlhan et al., 2018), Abrams Geriatric Self-
Neglect Scale (AGSS) (Abrams et al., 2018), Self-neglect Question-
naire (Peng et al., 2020), and Chinese version of the Elder Self-
Neglect Assessment (C-ESNA) (Wang, 2018).
The characteristics of the included self-neglect instruments
were presented in Table 1. These studies were published in En-
glish or Chinese from 2014 to 2020 and conducted in China
(n = 4) (Cai, 2015; Peng et al., 2020; Wang, 2018; Zhao, 2017),
the US (n = 2) (Abrams et al., 2018; Iris et al., 2014), Ire-
land (n = 1) (Day and McCarthy, 2016), and Turkey (n = 1)
(İlhan et al., 2018). Item generations were based on theoreti-
cal framework, literature review, the appraisal of existing instru-
ments, expert advice, questionnaire survey, and interviews. These
instruments can be self-reported (Iris et al., 2014; Zhao, 2017;
Wang, 2018; Peng et al., 2020), proxy-reported (Cai, 2015;
Day and McCarthy, 2016; İlhan et al., 2018), or both self-reported
and proxy-reported (Abrams et al., 2018). The target popula-
tion were community-dwelling older population (Iris et al., 2014;
Cai, 2015; Day and McCarthy, 2016; Zhao, 2017; Abrams et al.,
2018; İlhan et al., 2018; Wang, 2018) and inpatient older adults
(Peng et al., 2020). However, one study involved college students
(Cai, 2015), and the other one included public health nurses, social
workers, and senior case workers as research subjects (Day and
McCarthy, 2016). The number of items included in these instru-
ments was diverse, ranging from 6 to 62. Only one instrument has
both English and Chinese versions (Iris et al., 2014; Wang, 2018),
which we treated as two independent self-neglect instruments.
3.3. Results of methodological quality and measurement property
rating
The methodological quality and measurement property rating
against criteria for good measurement properties for each study
were presented in Table 2. None of the eight instruments identi-
fied were assessed for all measurement properties. Structural va-
lidity and internal consistency were the two most frequently re-
ported measurement properties in the included studies.
3.3.1. ESNA
ESNA (Iris et al., 2014) was the first developed self-neglect in-
strument for older adults, and has detailed measurement prop-
erties reported. ESNA was designed with two versions based on
a previous theoretical framework of concept mapping (Iris et al.,
2010): long version with 62 items and short version with 25 items.
The item generations of ESNA were established by 79 staff
members, including social workers, case managers, caseworkers,
elder abuse investigators, housing specialists, nurses, and client
advocates. The authors did not report the content validity index
(CVI) of the instrument. Therefore, its content validity was judged
as doubtful methodological quality and the measurement property
rating was indeterminate. Structural validity testing was performed
based on the Rasch measurement model. The variances explained
were 32.5% and 39.1% in the long and short versions, respectively.
The methodological quality of the structural validities of the two
versions was judged as very good and the measurement prop-
erty rating was sufficient. The methodological quality of hypoth-
esis testing for construct validity was inadequate because the con-
structs and measurement properties of the comparative instrument
 4
Table 1
Characteristics of the included studies.

Instrument Author, Year, Item generation Target Participants Mode of (Sub)scale (s) (number of Response options Range of scores Original Available
Country population administration items) language translated
version

Elder Iris et al., Based on theoretical community- community- self-report 62 items and 25 items Four choices: NA English Chinese
Self-Neglect 2014, US framework of concept dwelling older dwelling older with no subscales “yes’’, “no’’, “suspected’’,
Assessment mapping adults adults or “don’t know’’
(ESNA)
Elder Cai, 2015, Based on the literature community- college proxy-report 23 items divided into 4 Two choices: 0–23: Chinese None
Self–Neglect China review, expert advice, dwelling older students subscales: life style, “yes’’ or “no’’ Higher scores
Questionnaire questionnaire survey and adults healthcare, social indicate greater
(ESNQ) interviews interaction, and living self-neglect.
environment

M. Qian, Y. Shi, J. Lv et al. / International Journal of Nursing Studies 123 (2021) 104070
Self-Neglect-37 Day and Based on literature community- public health proxy-report 37 items divided into 5 A 5-point Likert scale: NA English None
(SN-37) McCarthy, review, ESN conceptual dwelling older nurses, social subscales: Environment, 1 (unimportant) to 5
2016, Ireland framework, previous adults workers, senior social networks, emotional (very important)
qualitative research and case workers and behavioral labiality,
the appraisal of existing health avoidance, and
instruments self-determinism
Scale of the Zhao, 2017, Based on the literature community- community- self-report 14 items divided into 5 A 5-point 0–28: Chinese None
Elderly China review, interviews,and an dwelling older dwelling older subscales: health care, Likert scale: Higher scores
Self-Neglect expert panel using Delphi adults adults hygiene, emotion, safety, 0 (absence of indicate greater
(Rural) (SESNr) technique and social interaction self-neglect) to 4 (highest self-neglect.
level of self-neglect)
Istanbul ILHAN et al., Based on combination of community- community- proxy-report 11 items divided into 3 Two choices: 0–11: Turkish None
Medical School 2018, Turkey homeinterviews and dwelling older dwelling older subscales: personal “yes’’ or “no’’ Lower scores
Elder examining multiple scales adults adults in hygiene, health habits, indicate higher
Self-Neglect outpatient social functioning possibility of
questionnaire clinics self-neglect.
(IMSelf-
neglect)
Abrams Abrams et al., Based on the geriatric community- community- self-report and 6 items with 6 subscales: A 5-point Likert scale: 0–24: English None
Geriatric 2018, US self-neglect literature and dwelling older dwelling older proxy-report prescription medicines, 0 (absence of Higher scores
Self-Neglect experts of local adults adults personal care, nutrition, self-neglect) to 4 (highest indicate greater
Scale (AGSS) psychiatrists, geriatricians, environment/housing, level of self-neglect) self-neglect.
and social workers financial stewardship,
socialization
Chinese Wang, 2018, Based on the original scale community- community- self-report 24 items divided into 3 Four choices: 0–48 English Chinese
version of the China (the ESNA scale) dwelling older dwelling older subscales: life “yes’’,“no’’,“suspected
Elder adults adults style/condition, health problem’’, or “don’t
Self-Neglect care, and living know’’
Assessment environment
(C-ESNA)
Self-neglect Peng et al., Based on former results of inpatient older inpatient older self-report 24 items divided into 7 Five choices: 24–120: Chinese None
Questionnaire 2020, China qualitative interviews, adults adults subscales: neglecting “strongly agree’’ “agree’’ The higher the
literature review and safety, neglecting hygiene, “neutral’’ “disagree’’ score is , the
Delphi expert consultation neglecting diet, neglecting “strongly disagree’’ greater the
emotional needs, possibility of
neglecting self-neglect
self-development, older adults
neglecting health care, have.
neglecting social
interaction
Note:
NA: not available.
 M. Qian, Y. Shi, J. Lv et al. / International Journal of Nursing Studies 123 (2021) 104070
Fig. 1. Detailed information of literature search and study selection.
were not mentioned. The measurement property rating of the hy-
pothesis testing for construct validity was sufficient. Internal con-
sistency of ESNA was rated as sufficient with Cronbach’s alpha of
0.91 for the long version and 0.87 for the short version. Moreover,
the methodological quality of internal consistency was assessed as
very good.
3.3.2. ESNQ
ESNQ (Cai, 2015) is a proxy-reported scale. College students
were invited to observe an older adult around them during
their holidays, and complete the questionnaire according to their
scrutiny and communications with that older person. Content va-
lidity was evaluated among 3 students, 4 experts and 2 social
workers. Given that the number of professionals used in the con-
tent validity assessment was below 30, the methodological qual-
ity of ESNQ was doubtful and the measurement property rating
of content validity was sufficient. The methodological quality of
the structural validity was deemed as very good and measurement
property was rated as sufficient, with explanation of 44.4% of the
variance and showing good fit to the original factor structure via
confirmatory factor analysis (CFA). The methodological quality of
5
hypothesis testing for construct validity was inadequate because
the constructs and measurement properties of the comparative in-
struments were not clear. Meanwhile, measurement property was
rated as sufficient because the results were in accordance with the
hypothesis. Internal consistency was calculated for the overall scale
with Cronbach’s alpha of 0.877 and for the subscales with Cron-
bach’s alphas from 0.804 to 0.869, which was assessed as very
good and sufficient in terms of the methodological quality and
measurement property rating, respectively.
3.3.3. SN-37
SN-37 (Day and McCarthy, 2016) is a proxy-reported scale,
and developed for professionals to rate the self-neglect of older
adults. The content validity of SN-37 was established by a panel
of eight experts with a variety of professional backgrounds. CVI
was 0.875 for the overall scale and 0.75 to 1.00 for each subscale.
The methodological quality of content validity was deemed doubt-
ful and the measurement property was rated as insufficient. The
methodological quality of structural validity was rated as very good
with the original structure confirmed by exploratory factor analysis
(EFA), explaining 56.5% of variance. The measurement property of
6 M. Qian, Y. Shi, J. Lv et al. / International Journal of Nursing Studies 123 (2021) 104070

Table 2
Brief summary of the methodological quality of the reviewed instruments.

Instrument Content Validity Structural Validity Internal Consistency Reliability Hypotheses testing
for construct validity

N MQ R N MQ R N MQ R N MQ R N MQ R

ESNA (Iris et al., 2014) experts and social services D ? 215 V + 215 V + n.r. n.r. n.r. 51 I +
practitioners (n = 50)
ESNQ (Cai, 2015) students (n = 3) D + 1173 V + 819 V + n.r. n.r. n.r. 819 I +
Experts (n = 4)
social workers (n = 2)
SN-37 (Day et al., 2016) experts (n = 8) D – 305 V + 305 V ? n.r. n.r. n.r. n.r. n.r. n.r.
SESNr (Zhao, 2017) experts (n = 23) D + 220 V + 181 V – NA D + 201 D –
older adults (n = 28)
IMSelf-neglect Older adults (n = 10) I ? n.r. n.r. n.r. 27 I + 253 D ? 90 I +
(ILHAN et al., 2018)
AGSS (Abrams et al., 2018) NA D ? n.r. n.r. n.r. 71 V – n.r. n.r. n.r. n.r. n.r. n.r.
C-ESNA (Wang, 2018) experts (n = 6) D + 649 V + 336 V + 30 D + 313 D +
older adults (n = 5)
SNQ (Peng et al., 2020) Experts (n = 19) older D + 314 A + 314 I ? n.r. n.r. n.r. n.r. n.r. n.r.
adults (n = 71)
Notes:
NA: not available;
n.r.: not reported;
MQ: methodological quality; R:Rating;
V:Very Good; A:Adequate; D:Doubtful; I:Inadequate;
+: sufficient; -:insufficient; ?: indeterminate;
ESNA: Elder Self-Neglect Assessment; ESNQ: Elder Self–Neglect Questionnaire;
SN-37: Self-Neglect-37; SESNr: Scale of the Elderly Self-Neglect (Rural);
IMSelf-neglect: Istanbul Medical School Elder Self-Neglect questionnaire;
AGSS: Abrams Geriatric Self-Neglect Scale; C-ESNA: Chinese version Elder Self-Neglect Assessment;
SNQ: Self-neglect Questionnaire.

structural validity was rated as sufficient. The measurement prop-
erty of internal consistency was rated as indeterminate because the
alpha of some of the subscales was below 0.7. The methodological
quality of internal consistency was deemed very good.
3.3.4. SESNr
SESNr (Zhao, 2017) was developed to assess the self-neglect of
older adults in China’s rural areas. The methodological quality of
content validity was regarded as doubtful because the number of
experts representing the comprehensiveness and relevance was in-
adequate and measurement property was rated as sufficient. The
structural validity of the scale was tested using CFA explaining
68.23% of the variance, and methodological quality was judged to
be very good and the measurement property rating of the result
was sufficient. The Assessment of Self-Neglect Severity (ASS) scale
was used for hypothesis testing for construct validity (Dong et al.,
2009), and the correlation coefficient between the two scales was
0.370. The methodological quality of hypothesis testing for con-
struct validity was doubtful because minimal information could be
referred to regarding the measurement properties of ASS; mea-
surement property rating was insufficient because the result did
not agree with the hypothesis (correlation coefficient: 0.4 to 0.8)
(Zhao, 2017). The methodological quality of internal consistency
was very good and the measurement property rating of the inter-
nal consistency of SESNr was insufficient because Cronbach’s al-
pha was 0.779 for the overall scale and 0.623–0.779 for the sub-
scales. The methodological quality of reliability was doubtful be-
cause conditions for the tests were not described, and the mea-
surement property rating was sufficient with infraclass correlation
(ICC) of 0.747.
3.3.5. IMSelf-neglect
IMSelf-neglect (İlhan et al., 2018) was designed in Turkey
and developed for self-neglect among community-dwelling self-
sufficient older adults admitted to outpatient clinics. The method-
ological quality of content validity was rated as inadequate because
the relevance of all items has not been reported. The measurement
property rating of content validity was indeterminate. The method-
ological quality of the hypothesis testing for construct validity was
inadequate because the constructs and measurement properties of
the comparative instruments were not reported. The measurement
property rating of the result of the hypothesis testing for con-
struct validity was sufficient. The methodological quality of inter-
nal consistency was rated as inadequate because the internal con-
sistency of the subscales was not calculated and Cronbach’s alpha
was 0.708. The measurement property was rated as sufficient. The
ICC of test–retest reliability was 0.942. The methodological quality
of reliability was doubtful and the measurement property rating of
the result was indeterminate.
3.3.6. AGSS
AGSS (Abrams et al., 2018), which was originally called the Cor-
nell Scale for Self-Neglect, was developed to identify the clini-
cal characteristics of older adults who have self-neglect and eval-
uate self-neglect independent of comorbid medical and psychi-
atric conditions (Abrams et al., 2002). The scale has six domains,
and the scores of these domains can be given based on the sub-
jects’ responses, observers’ ratings, and overall impressions (infor-
mation sources were from clinicians, family members, and non-
relative caregivers). The methodological quality of content validity
was doubtful and measurement property rating of the result was
indeterminate. The methodological quality of internal consistency
was very good and the measurement property of internal consis-
tency was rated as insufficient with Cronbach’s alpha calculated at
0.681 of the subject responses and 0.758 of the observer responses.
3.3.7. C-ESNA
C-ESNA (Wang, 2018) is a Chinese version of ESNA to assess
the self-neglect of Chinese community-dwelling older adults.
Content validity was assessed by asking experts and older adults
about comprehensiveness, relevance, and/or comprehensibility.
Scale-level CVI was 0.97 and the item-level CVI was 0.83 to 1. The
methodological quality of content validity was doubtful and mea-
surement property rating was sufficient. CFA was performed with
 M. Qian, Y. Shi, J. Lv et al. / International Journal of Nursing Studies 123 (2021) 104070
53.27% of the cumulative percentage of variance. The methodolog-
ical quality of structural validity was very good and measurement
property rating was sufficient. Hypothesis testing for construct
validity was conducted through a comparison with the Social
Support Rating Scale (Xiao, 1994), and the methodological quality
of hypothesis testing for construct validity was doubtful and its
measurement property rating was sufficient. The methodological
quality of internal consistency was very good and the measure-
ment property rating of internal consistency was sufficient with
Cronbach’s alpha of 0.918 for the overall tool and 0.803 to 0.884
for each subscale. Test–retest reliability was assessed within a
two-week interval, and ICC was 0.893. The methodological quality
and measurement property of the test–retest reliability were
doubtful and sufficient, respectively.
3.3.8. Self-neglect questionnaire
The Self-neglect Questionnaire (Peng et al., 2020) was de-
veloped to evaluate the self-neglect of older adults who were
hospitalized. Content validity of the Self-neglect Questionnaire
was assessed by 19 experts and 71 older adults, who reviewed the
comprehensiveness, relevance and/or comprehensibility. Scale-level
CVI was 0.987 and item-level CVI was 0.895 to 1. The methodolog-
ical quality of content validity was doubtful because the number
of experts was below 30, and measurement property rating was
sufficient because the experts and target population were involved
in the process. Structural validity testing was performed via EFA
with 69.39% of the cumulative percentage of variance explained.
The methodological quality of structural validity was adequate and
its measurement property rating was sufficient. The measurement
property of internal consistency was rated as indeterminate and
the methodological quality was inadequate because only the
internal consistency of the overall scale was assessed.
4. Discussion
In this review, eight instruments were identified to assess self-
neglect in older adults. To the best of our knowledge, this sys-
tematic review is the first to critically appraise the methodolog-
ical qualities and the quality of measurement properties of each
self-neglect instrument according to the COSMIN methodology
(Mokkink et al., 2018a,b; Prinsen et al., 2018; Terwee et al., 2018).
No studies have mentioned all the measurement properties accord-
ing to the COSMIN Risk of Bias checklist (Mokkink et al., 2018a) ,
particularly such criteria as measurement error, cross-culture va-
lidity, and responsiveness. In general, no clear evidence has shown
that one instrument is superior to others. Accordingly, research ef-
fort is needed for understanding the self-neglect of older adults
and instrument development. Although multiple instruments have
been available to assess self-neglect of older adults, numerous
challenges still have to be addressed.
Content validity, which refers to the relevance, comprehensive-
ness, and comprehensibility of an instrument, is often recognized
as the most important measurement of PROMs (Terwee et al.,
2018). A lack of high methodological quality of content valid-
ity can affect all other measurement properties (Terwee et al.,
2018). Conversely, a rigorous and valid instrument with good con-
tent validity can contribute to the overall development of high-
quality assessment in self-neglect. However, the methodological
qualities of content validity of all studies in this systematic re-
view were “doubtful” or “inadequate.” No studies adhered to the
minimum 30 experts for content validity assessment suggested by
COSMIN Risk of Bias checklist (Mokkink et al., 2018a). A com-
mon phenomenon is a doubtful and inadequate methodological
quality of content validity according to numerous instrument sys-
tematic reviews (Gondivkar et al., 2019; Charette et al., 2020;
7
Middlebrook et al., 2021). On the one hand, researchers are un-
aware of the basic standards for content validity assessment pro-
posed by COSMIN Risk of Bias checklist. On the other hand, the
minimum number of experts for content validity evaluation is wor-
thy of further careful discussions and verifications based on and
beyond the COSMIN Risk of Bias checklist.
CFA and EFA are beneficial for structural validity evaluation
when classical test theory is used (Floyd and Widaman, 1995).
According to the COSMIN Risk of Bias checklist (Mokkink et al.,
2018a), CFA is preferred over EFA and only the criteria of CFA
are available for the methodological quality of structural validity.
Two instruments in the current review (Day and McCarthy, 2016;
Peng et al., 2020) used EFA to test the structural validity of their
instruments. Although no concrete criteria were provided for as-
sessing the results of the two studies in COSMIN Risk of Bias
checklist, the research team made the final judgments based on
their expertise. We suggest that future studies adopt CFA as the
main method to evaluate the structural validity of the instruments
they develop. Moreover, detailed criteria for assessing the results of
studies using EFA should also be explored and listed in the COS-
MIN Risk of Bias checklist to facilitate the consistent reports and
comparisons of the methodological quality of the reviewed instru-
ments.
Three studies (Iris et al., 2014; Cai, 2015; İlhan et al., 2018)
in this systematic review did not clearly report the measurement
properties of the comparable instruments when they conducted
hypothesis testing of the construct validity. In general, the more
specific the hypotheses are, the more supportive evidence the con-
struct validity has (Strauss and Smith, 2009). When a newly de-
veloped instrument is compared to another instrument, the em-
phasis is that the constructs of the comparable instruments should
be described in detail. The instrument itself should be of sufficient
quality as well. Future self-neglect instrument development stud-
ies should report the measurement properties of the comparable
instruments if it is applicable.
In our review, three studies (Zhao, 2017; İlhan et al., 2018;
Wang, 2018) reported the test–retest reliability of the instruments,
although these studies’ methodological qualities were doubtful.
The common problem of the methodological quality of the test–
retest reliability was that researchers did not describe whether the
conditions of two tests were similar. Guided by the COSMIN Risk
of Bias checklist (Mokkink et al., 2018a) , we propose that the con-
ditions of the two tests for the test–retest reliability (e.g., type of
administration, setting where the instruments are administered)
should be provided.
The self-neglect instruments in our review can be completed
by older adults themselves or by other relevant personnel, includ-
ing professionals, university students, caregivers, and family mem-
bers. We have difficulties in identifying which method is better
owing to the following considerations. First, given that the older
people with self-neglect may have cognitive problems with vari-
ous level (Abrams et al., 2002; Dong et al., 2010; X. Dong, Simon,
Mosqueda et al., 2012; Dong and Simon, 2016), they are relatively
unable to conduct an accurate self-assessment of themselves. Fur-
thermore, self-neglect is a life choice by some older people, and
they may be reluctant to report the real situation to avoid embar-
rassment. Some other instruments are proxy-reported, and these
scales are answered by caregivers, family members, or profession-
als, whose scrutiny and knowledge of older adults are the main
judgment references. However, proxy-reported tools lack the capa-
bility to detect the personal attributes on the self-neglect of older
adults. The reason is that the contents are considerably focused
on the measurement of external environments and behaviors that
can be observed by others. Second, one of the inclusion criteria
of some studies that used self-reported instrument (Abrams et al.,
2018; Wang, 2018; Peng et al., 2020) is that older adults should
8 M. Qian, Y. Shi, J. Lv et al. / International Journal of Nursing Studies 123 (2021) 104070
be cognitively intact. As understood, the self-neglect phenomenon
is particularly common among older adults with cognitive dete-
rioration. Exclusion of older adults with impaired cognitive func-
tion may contribute to underestimation and underrecognition of
the self-neglect of older population. Therefore, we suggest that
self-reported and proxy-reported methods may be considered to
be combined in one instrument with two sessions. In addition,
older adults with mild cognitive dysfunction should also be re-
tained as eligible participants when a self-neglect instrument is
developed.
This systematic review has some limitations that should be
noted. First, we only included studies published in English and
Chinese, thereby possibly resulting in missing some instruments
developed or translated in other languages. Second, although we
conducted a systematic search strategy using the corresponding
terms, some articles may still be left out. Third, minimal infor-
mation on the measurement properties of cross-cultural valid-
ity/measurement invariance, measurement error, criterion validity,
and responsiveness can be obtained from the majority of the re-
viewed instruments.
5. Conclusions
This systematic review provides a comprehensive overview of
the quality of measurement properties and methodological quality
of self-neglect instruments for older adults. Among the eight in-
struments identified, none has demonstrated better quality than
any other. With this review, we recommend that future studies
should consider COSMIN methodology (Mokkink et al., 2018a,b;
Prinsen et al., 2018; Terwee et al., 2018) as an instrument develop-
ment guideline. Self-reported and proxy-reported methods should
be adopted in one instrument to obtain the entire and accurate
picture of self-neglect in older adults.
Declaration of Competing Interest
None.
Funding sources
This work was supported by the Fundamental Research Funds
for the Central Universities (Grant No. BMU2021YJ022). The funder
did not play any role in the conduct or publication of the study.
Supplementary materials
Supplementary material associated with this article can be
found, in the online version, at doi:10.1016/j.ijnurstu.2021.104070.
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