Received: 26 October 2022 | Revised: 11 September 2023 | Accepted: 27 September 2023

DOI: 10.1111/jan.15898

R E S E A R C H M E T H O D O LO G Y:
D I S C U S S I O N P A P E R - ­ M E T H O D O L O G Y

Frailty in community-­dwelling older people and nursing home

residents: An adaptation and validation study

Sergej Kmetec1 | Zvonka Fekonja1 | Adam Davey2 | Barbara Kegl1 |

Jernej Mori3 | Nataša Mlinar Reljić1 | Brendan McCormack4 | Mateja Lorber1

1
Faculty of Health Sciences, University of
Maribor, Maribor, Slovenia
2
College of Health Sciences, University of
Delaware, Newark, USA
3
Emergency Department, University
Clinical Centre Maribor, Maribor, Slovenia
4
University of Sydney Susan Wakil School
of Nursing, Camperdown, New South
Wales, Australia
Correspondence
Sergej Kmetec, Faculty of Health Sciences,
University of Maribor, Žitna ulica 15,
Maribor, Slovenia.
Email: sergej.kmetec1@um.si
Funding information
Foundation for the National Institutes
of Health, Grant/Award Number:
R01CA194178; Javna Agencija za
Raziskovalno Dejavnost RS, Grant/Award
Number: BI-­US/22-­24-­096
Abstract
Aim: The aim of this was to psychometrically adapt and evaluate the Tilburg Frailty
Indicator to assess frailty among older people living in Slovenia's community and nurs-
ing home settings.
Design: A cross-­cultural adaptation and validation of instruments throughout the
cross-­sectional study.
Methods: Older people living in the community and nursing homes throughout Slovenia
were recruited between March and August 2021. Among 831 participants were 330
people living in nursing homes and 501 people living in the community, and all were
older than 65 years.
Results: All items were translated into the Slovene language, and a slight cultural ad-
justment was made to improve the clarity of the meaning of all items. The average
scale validity index of the scale was rated as good, which indicates satisfactory con-
tent validity. Cronbach's α was acceptable for the total items and subitems.
Conclusions: The Slovenian questionnaire version demonstrated adequate internal
consistency, reliability, and construct and criterion validity. The questionnaire is suit-
able for investigating frailty in nursing homes, community dwelling and other settings
where older people live.
Impact: The Slovenian questionnaire version can be used to measure and evaluate
frailty among older adults. We have found that careful translation and adaptation pro-
cesses have maintained the instrument's strong reliability and validity for use in a new
cultural context. The instrument can foster international collaboration to identify and
manage frailty among older people in nursing homes and community-­dwelling homes.
Reporting Method: The Strengthening the Reporting of Observational Studies in
Epidemiology checklist for reporting cross-­sectional studies was used.
No Patient or Public Contribution: No patient or public involvement in the design or
conduct of the study. Head nurses from nursing homes and community nurses helped
recruit older adults. Older adults only contributed to the data collection and were col-
lected from nursing homes and community dwelling.

KEYWORDS
aged, chronic disease, frailty, instrument validation

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© 2023 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.

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2 KMETEC et al.
1 | I NTRO D U C TI O N
Frailty is associated with loss of biological reserves, failure of
physiological mechanisms, vulnerability related to many negative
consequences (Clegg et al., 2013) and ageing (Feng et al., 2017). It
is not the same as multi-­m orbidity but is often related to chronic
disease or disability and potentially to late-­life dependency
(Vetrano et al., 2019). A frail person has a higher risk of daily liv-
ing limitations (Liu et al., 2019). Frailty is a public health priority
worldwide (Hoogendijk et al., 2019). Defining frailty is challeng-
ing for several reasons, including the complex aetiology (Clegg
et al., 2013); independent researchers' work (Karunananthan
et al., 2009); and the complexity of ageing frailty and disability
(Vetrano et al., 2019). The World Health Organization and the
International Association of Geriatrics and Gerontology are
working towards developing an internationally acceptable defini-
tion of frailty (Berrut et al., 2013).
Frailty is associated with age, gender, economic status (Feng
et al., 2017) and chronic disorders (James et al., 2018). The incidence
rate of frailty varies across countries and is expected to increase
based on the projected demographics (Ofori-­A senso et al., 2019).
Based on a literature review (Collard et al., 2012), of 21 cohorts with
61,500 participants, 10.7% of community-­dwelling older people
(65+) are frail, and another 41.6% are prefrail. Prevalence of frailty in
nursing homes ranged from 19% to 75.6%, and approximately 40%
were prefrail (Kojima, 2015). From another literature review, preva-
lence rates for adults ≥50 years of age from 62 countries resulted in
an overall estimate of 12% (11%–­13%) for physical frailty (O'Caoimh
et al., 2021).
Despite the importance of frailty for understanding the effects
of population ageing, global fragility prevalence remains unclear
(O'Caoimh et al., 2021). Fortunately, frailty is a dynamic geriatric
syndrome that can be mitigated with appropriate intervention strat-
egies (Kidd et al., 2019).
The Tilburg Frailty Index (TFI) is one of the self-­administered
questionnaires (Gobbens et al., 2010, 2012) that has been used in-
creasingly to assess frailty among older people since 2010 (Gobbens
& Uchmanowicz, 2021). It contains 15 physical, psychological and
social items (Gobbens & Uchmanowicz, 2021).
The review found that 27 studies reported the psychomet-
ric properties of the TFI in terms of reliability, validity, or both.
Twenty-­seven focused on older people in shared accommodations
(Gobbens & Uchmanowicz, 2021). In 2020, internal consistency,
convergent and divergent validity were assessed as simultaneous
validity of the TFI for older people in community dwelling in Spain,
Greece, Croatia, the Netherlands and the United Kingdom (Zhang
et al., 2020). The questionnaire is valid and reliable for older people
in community dwelling (Gobbens et al., 2010; Gobbens & Uchmano-
wicz, 2021; Gobbens & van Assen, 2014) but not for older people
in a nursing home.
This study aimed to adapt and evaluate, psychometrically, the
Tilburg Frailty Indicator to assess frailty among older people living in
both community and nursing home settings in Slovenia.
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2 | M E TH O D O LO G Y
Content, face validity and internal consistency reliability were as-
sessed along with exploratory factor analysis on the Tilburg Frailty
Indicator in Slovenia (TFI-­SI). For conducting psychometric testing,
we follow the recondition of Polit and Beck (2021), and for reporting
a cross-­sectional study, we follow the Strengthening the Reporting
of Observational Studies in Epidemiology checklist.
2.1 | Instrument
TFI is a 15-­item questionnaire measuring frailty in older people.
TFI consists of three domains: (1) Physical components (Ph) (eight
questions); (2) Psychological components (Ps) (four questions); and
(3) Social components (So) (three questions). The score range of Ph
is from 0 to 8, Ps are scored from 0 to 4, and So are scored from
0 to 3. Eleven items had two possible answers (yes and no), and
four items had three possible answers (‘yes’, ‘sometimes’ and ‘no’).
Total scores ranged from 0 to 15 (Gobbens et al., 2010), with ≥5
points indicating frailty in an older person (Gobbens et al., 2010;
Vetrano et al., 2019).
2.2 | Validation regarding the experts' agreement
2.2.1 | The process of translating the questionnaire
The TFI questionnaire was translated from the first author into
Slovene with the author's permission. An independent bilingual
translator and a nursing language expert conducted the back
translation. After back translation, both questionnaire versions
were reviewed, harmonized and formulated the final version.
Other authors (an expert in caring for older people) reviewed and
discussed both versions and approved the final questionnaire. No
problems were encountered in translating the questionnaire. To
achieve semantic equivalence, we used back translation so that
the meaning of each item in the target culture after translation
would be the same as in the original (Polit & Beck, 2021). The items
in the translated version are easy to understand, and the question-
naire can be completed in less than 15 min, which is comparable
to other versions of questionnaires (Dent et al., 2016; Gobbens
et al., 2010, 2012; Gobbens & Uchmanowicz, 2021; Gobbens &
van Assen, 2014).
2.2.2 | Content validity
To assess the validity of the content of the translated question-
naire, 10 people with expertise in the care of older people re-
viewed the questionnaire and rated each element for its relevance
using a four-­p oint scale. Item content validity index (I-­C VI), scale
content validity index (S-­C VI) (Shi et al., 2012) and average scale

KMETEC et al.
validity index (S-­C VI/Ave) were calculated. The scores were rated
good when I-­C VI was >0.78 and S-­C VI/Ave was >0.90 (Polit &
Beck, 2021). We calculated a modified kappa (κ*) statistic to re-
duce the influence of chance agreement. To evaluate the modified
κ*, we followed the recommendations of Cicchetti and Spar-
row (1981), and Polit et al. (2007). They divided the values into
three groups, namely moderate (0.40–­0 .59), good (0.60–­0 .75) and
excellent (>0.75).
2.2.3 | Face validity and cultural adaptation
Face validity and cultural adaptation were tested with the same con-
venience sample of 10 experienced nurses in older people's nurs-
ing care. Participants were asked to suggest better wording if items
were identified as unclear. If comments or corrections were given,
the authors discussed this, and after reaching a consensus, the fin-
ished version of the questionnaire was confirmed (Data S1).
2.3 | Cross-­sectional study
The internal consistency of the TFI-­SI was assessed in a cross-­
sectional study using a convenience sample (Polit & Beck, 2021). The
inclusion criteria for the study were older adults (aged 65 and over)
living in nursing homes and community dwelling. Participants were
required to have the cognitive capability to assess their frailty using
the TFI (cognitive ability was assessed so that the healthcare pro-
fessional considered which participants could be offered to partici-
pate in the study. In doing so, they looked at the absence of known
organic or psychiatric affecting cognitive ability). Exclusion criteria
were younger adults than 65 years living in nursing homes and com-
munity dwelling and cognitive impairment to answer the question.
2.3.1 | Data collection
Data collection took place between March and August 2021 and
took place in Slovenian nursing homes and community dwelling after
the participants gave written consent. Nurses working in community
nursing and who visit older people living at home helped us distrib-
ute questionnaires to community dwelling older adults.
Five researchers distributed and assisted older people in com-
pleting the questionnaires. All researchers received standardized
data collection training for this study and were familiarized with
the questionnaire, including the collection of demographic infor-
mation and item responses. The survey was completed using a pen-
cil and paper.
At each sampling location, older people were recruited with the
help of the head nurse and community health nurses. After obtaining
consent for the implementation, the interviewers introduced them-
selves to the participants in their homes and nursing homes and then
explained the purpose of this study. Verbal informed consent was
|
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3
obtained before the respondents filled out the questionnaire. We
asked the participants to fill out the questionnaire independently
and allowed them to have the questions explained to them if neces-
sary. For those who were visually impaired or illiterate, the research-
ers made it possible to complete the questionnaire by reading the
questions to the participants. Participants could skip a question if
they did not understand it or did not want to answer it. When data
were being collected, participants could quit at any time.
The sample size was determined using the Cochran formula and
estimated that the representative sample should be 384 (e = 95%;
z = 5%). The researchers distributed 1010 questionnaires, of which
888 were returned. Due to missing data (over 50% of the ques-
tionnaire), 22 questionnaires were removed; therefore, we had 866
questionnaires included in the analysis (response rate: 87.9%).
2.3.2 | Analysis of the data
Using IBM SPSS v28.0, we created a database and used it for de-
scriptive and inferential analysis and checked for accuracy. Descrip-
tive statistics (mean and standard deviation) were estimated with
95% confidence intervals. Internal consistency was assessed with
Cronbach's coefficient ɑ, omega coefficient and item-­total correla-
tions. The Cronbach's coefficient ɑ was judged based on the Nun-
nally (1978) recommendations (adequate [>0.7], excellent [>0.9]).
With the calculation of intraclass correlation coefficients, the
test–­retest reliability was estimated. As part of the test–­retest pro-
cedure, the participants were asked to answer the TFI-­SI twice, ap-
proximately 3 months apart. The intraclass correlation coefficients
were elevated based on recommendations from Cicchetti and Spar-
row (1981) (good [>0.6], excellent [>0.75]). The previous step helped
us calculate the reproducibility of the Slovenian, and Pearson's cor-
relation coefficient enabled us to present the reproducibility (Vaz
et al., 2013). Adjusted correlations of each item with their respective
scales were also assessed, with values of 0.2 < r < 0.3 considered ac-
ceptable (Mahieu et al., 2013).
Exploratory factor analysis was performed using the Kaiser–­
Meyer–­Olkin and Bartlett's test for sampling adequacy. Factor anal-
ysis was used to determine the covariance of the scale items, which
warranted factor analysis. In addition, factor analysis using Direct
Oblimin rotation was used. Factor extraction was based on parallel
analysis for Eigenvalues equal to or greater than one and a scree plot
(Patil et al., 2007).
2.4 | Ethical considerations
We obtained the relevant Ethics Committee for approval
(038/2018/2510-­1/504). Participants were informed in writing of
the purpose of the study and objectives, highlighting confidential-
ity, anonymity, and voluntary withdrawal from participation at any
research stage. On request, results obtained from the study will
be shared with participants. The authors follow the Declaration of
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4 KMETEC et al.

Helsinki (World Medical Association, 2001) and the Oviedo Conven- 3.3 | Face validity
tion (Council of Europe, 2001).
Experts suggested clarifying the items' meaning with minor cultural
adaptations, and no items were removed.
3 | R E S U LT S

3.1 | Validation based on experts' agreement 3.4 | Psychometric testing based on a

cross-­sectional study
We encountered no problems with the translated items throughout
the expert review, and no changes or deletions were necessary. 3.4.1 | Participants

We distributed 1010 questionnaires, and 888 were returned; therefore,

3.2 | Content validity
The content validity of all items of the TFI-­SI questionnaire is pre-
sented below (Table 1). All items had an I-­C VI score of at least 0.60.
Based on the κ* coefficient the items Ph1 (I-­C VI = 0.80), Ph3 (I-­
CVI = 0.80), Ph4 (I-­C VI = 0.90), Ph6 (I-­C VI = 0.80), Ph7 (I-­C VI = 0.90),
Ph8 (I-­C VI = 1.00), Ps1 (I-­C VI = 0.80), Ps2 (I-­C VI = 0.80), Ps4 (I-­
CVI = 0.80) and So1 (I-­C VI = 0.80) were evaluated as excellent. Items
Ph2 (I-­C VI = 0.70), Ph5 (I-­C VI = 0.70), Ps3 (I-­C VI = 0.70) and So2
(I-­C VI = 0.60) evaluated as good. The S-­C VI/Ave was estimated at
0.793.
there were 122 non-­responders. The analysis included 866 question-
naires after 22 were removed owing to missing data. Among our overall
sample of 866 older people, 35.5% (n = 307) were male, and a majority
lived in the community (60.6%; n = 525), and 39.4% (n = 341) lived in
nursing homes. The mean age of participants was 76.5 (SD = 9.2) (95%,
CI = 75.1–­77.1). The mean age of community-­dwelling older people
was 74.9 years (SD = 9.5) (95%, CI = 74.1–­75.7) and 79.0 years (SD = 9.0)
(95%, CI = 78.1–­80.0) for older people living in a nursing home. Fifty-­
two-­point 3% (n = 453, 95%, CI = 56%–­63%) of all participants had one
chronic disease, including 57.9% (95%, CI = 53%–­63%) of community-­
dwelling older people and 47.2% (95%, CI = 55%–­66%) of those from

TA B L E 1 Content validity of the Tilburg Frailty Indicator in Slovenia questionnaire.

No. Item N A I-­C VIa Pcb κ*c Evaluationd

Ph1 Do you feel physically healthy? 10 8 0.80 0.00 0.80 Excellent

Ph2 Have you lost a lot of weight? 10 7 0.70 0.00 0.70 Good
Ph3 Do you experience problems due to difficulty in 10 8 0.80 0.00 0.80 Excellent
walking?
Ph4 Do you experience problems due to difficulty in 10 9 0.90 0.00 0.90 Excellent
maintaining your balance?
Ph5 Do you experience problems due to poor hearing? 10 7 0.70 0.00 0.70 Good
Ph6 Do you experience problems due to poor vision? 10 8 0.80 0.00 0.80 Excellent
Ph7 Do you experience problems due to a lack of 10 9 0.90 0.00 0.90 Excellent
strength in your hands?
Ph8 Do you experience problems due to physical 10 10 1.00 0.00 1.00 Excellent
tiredness?
Ps1 Problems with your memory? 10 8 0.80 0.00 0.80 Excellent
Ps2 Felt down during the last month? 10 8 0.80 0.00 0.80 Excellent
Ps3 Nervous or anxious during the last month? 10 7 0.70 0.00 0.70 Good
Ps4 Are you able to cope with problems well? 10 8 0.80 0.00 0.80 Excellent
So1 Do you live alone? 10 8 0.80 0.00 0.80 Excellent
So2 Miss having people around you? 10 6 0.60 0.01 0.60 Good
So3 Enough support from other people? 10 8 0.80 0.00 0.80 Excellent
e
S-­C VI/Ave 0.793

Abbreviations: A—­No. of agreement; N—­No. of experts; Ph—­physical domain; Ps—­psychological domain; So—­social domain.
a
Item content validity index/ number giving
[ a rating
[ ] of 3 or 4/number of experts.
b
]
Pc (probability of a chance occurrence) = Pc = N!
A!
× (N − A) × 0.5N.
c
k* = kappa designating agreement on relevance.
d
Evaluation criteria for kappa: moderate = k of 0.40–­0.59; good = k of 0.60–­0.74; and excellent = k > 0.75.
e
S-­C VI/Ave (average scale validity index) = mean of I-­C VI.
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KMETEC et al. 5

nursing homes (Table 2). The estimated prevalence of frailty was 45% test (χ2 = 334.81, df = 105, p < .001) showed acceptable values.
overall (n = 390; 95%, CI = 39.8–­50.3); among older adults from nursing Then, we assessed commonalities, that is the proportion of vari-
homes, the estimated prevalence was 59% (n = 193; 95%, CI = 53.3–­ ance explained by the common factors. In general, we can claim
63.6), and among community-­dwelling older adults, estimated preva- that all three components have no value close to zero depending
lence was 36% (n = 183; 95%, CI = 32.5–­40.9). The prevalence of frailty on the factors. Principal axis factoring showed three factors that
among women was 50.5% (n = 279; 95%, CI = 46.3–­54.8) and among explained 65.6% of the variance. The first factor explained 41.3%
men 35% (n = 97; 95%, CI = 29.9–­40.6). and included eight questions focusing on coping with everyday
life, with factor loadings between 0.56 and 0.77. The second ex-
plained 16.3% and consisted of four questions that focused on
3.4.2 | Internal consistency psychological well-­b eing and had factor loadings of 0.53 and 0.78.
The last factor explained 8.0%, consists of three questions that
The Cronbach's coefficient α of the TFI-­SI questionnaire was evalu- focus on coping with problems and support and had factor load-
ated as adequate (0.79), and the McDonald Omega coefficient was ings of 0.60 and 0.82 (Table 5).
evaluated as adequate (0.76). Table 3 presents Pearson's correlations
between item scores and the total score. All items showed signifi-
cant item-­total correlations and ranged between 0.129 and 0.702
(p < .001). The strongest correlations between components were TA B L E 3 Pearson's correlation item-­total correlation of the
from the Ph (rp = 0.878; p < .001), the Ps (rp = 0.588, p < .001) and the Tilburg Frailty Indicator in Slovenia (TFI-­SI) questionnaire.
lowest item-­total correlation value was the So (rp = 0.515, p < .001).
Corrected Total alpha
Among community-­dwelling older people, a corrected item-­total
item-­total if item is
correlation ranged from 0.54 to 1.00; if an item is deleted, it ranged Component of TFI-­SI correlation deleted
from 0.48 to 0.81 (Table 4). Among older people living in nursing
Physical component 0.878 0.795
homes, item-­total correlations ranged from 0.53 to 1.00, if an item is
Do you feel physically healthy? 0.439 0.783
deleted from 0.38 to 0.76. Cronbach's coefficient ɑ for community-­
Have you lost a lot of weight? 0.212 0.792
dwelling older people was 0.77 (95%, CI = 0.74–­0.80), and for those
Do you experience problems 0.673 0.772
in a nursing home was also 0.76 (95%, CI = 0.67–­0.76). Intraclass cor-
due to difficulty in walking?
relation coefficient for the total TFI score was 0.79 (95%, CI = 0.72
Do you experience problems 0.637 0.773
to 0.81, p < .001). The TFI-­SI instrument has high within-­subject re-
due to difficulty in
liability based on the intraclass correlation coefficients above 0.70. maintaining your balance?
Do you experience problems 0.580 0.776
due to poor hearing?
3.5 | Construct validity Do you experience problems 0.541 0.778
due to poor vision?
Exploratory factor analysis of the TFI-­S I questionnaire among Do you experience problems 0.702 0.771
older people suggested three factors (Table 5). The Kaiser–­M eyer–­ due to a lack of strength in
your hands?
Olkin (KMO index is adequate at 0.829) and Bartlett's sphericity
Do you experience problems 0.593 0.777
due to physical tiredness?
TA B L E 2 Characteristics of the participants.
Psychological component 0.588 0.770
Descriptive statistics Problems with your memory? 0.300 0.789
Felt down during the last 0.592 0.775
Community
month?
Nursing home dwelling
Variables Total (n = 866) (n = 341) (n = 525) Nervous or anxious during the 0.129 0.795
last month?
Gender % (n) —­ —­ —­
Are you able to cope with 0.252 0.808
Male 35.5 (307) 30.5 (104) 36.4 (191) problems well?
Female 64.5 (559) 69.5 (237) 63.6 (334) Social component 0.515 0.780
Age (year; mean ± SD) 76.47 ± 1.15 79.01 ± 9.04 74.86 ± 9.48 Do you live alone? 0.585 0.789
No. of CD % (n) —­ —­ —­ Miss having people around you? 0.363 0.786
None 14.8 (128) 14.4 (49) 14.7 (77) Enough support from other 0.453 0.797
One 52.3 (453) 47.2 (161) 57.9 (304) people?
Two to three 31.5 (273) 36.7 (125) 26.7 (140) Cronbach's alpha 0.79 (95%, CI = 0.772–­0.813)
Four or more 1.4 (12) 1.7 (6) 0.7 (4) Mean ± standard deviation 7.02 ± 3.15 (95%, CI = 6.80–­7.23)
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6 KMETEC et al.

TA B L E 4 Pearson's correlation item-­

Community dwelling Nursing homes
total correlation coefficients differences
between older people living in nursing Component of Corrected item-­ Total alpha if Corrected item-­ Total alpha if is
homes and community dwelling of the TFI-­SI total correlation item is deleted total correlation item deleted
Tilburg Frailty Indicator in Slovenia (TFI-­
Physical 0.875 0.521 0.865 0.741
SI) questionnaire.
component
Psychological 0.585 0.794 0.582 0.733
component
Social component 0.538 0.808 0.533 0.756
Total TFI-­SI 1.000 0.475 1.000 0.384
Cronbach alpha 0.77 (95%, CI = 0.738–­0.803) 0.76 (95%, CI = 0.723–­0.798)
Mean ± standard 6.39 ± 3.23 (95%, CI = 6.12–­6.68) 7.98 ± 2.76 (95%, CI = 7.68–­8.27)
deviation

TA B L E 5 Exploratory factor analysis of the Tilburg Frailty

Indicator in Slovenia questionnaire. 4 | DISCUSSION

Factor loadings
The aim of this article was the translation and cross-­cultural adapta-
Component Factor 1 Factor 2 Factor 3 tion of the TFI for the Slovenian population. This study evaluated
Do you feel physically healthy? (Q11) 0.636 —­ —­ the physical, psychological and So of a Slovene language version of

Have you lost a lot of weight 0.573 —­ —­

the TFI questionnaire, enabling an analysis of frailty in older peo-
recently without wishing to do ple living in nursing homes and community dwelling. The translation
so? (Q12) process is a crucial aspect of test adaptation in general and assur-
Do you experience problems in 0.714 —­ —­ ing, in particular, semantic equivalence (Polit & Beck, 2021). The
your daily life due to difficulty in TFI questionnaire was translated into Slovenian and validated. To
walking? (Q13)
ensure semantic equivalence, we used independent translation and
Do you experience problems in 0.742 —­ —­
back translation to ensure the equality of meaning of each item of
your daily life due to difficulty
the original text according to the translated items. The first author
maintaining your balance? (Q14)
translated the questionnaire items to the target language; a second
Do you experience problems in your 0.770 —­ —­
daily life due to poor hearing? bilingual translator independently back-­translated the questionnaire
(Q15) from the target language to the original language. The two versions
Do you experience problems in your 0.708 —­ —­ of the questionnaire were compared for equivalence. This procedure
daily life due to poor vision? continued until a research team agreed that the conceptual mean-
(Q16)
ing of the two questionnaire versions was identical. The Slovenian
Do you experience problems in your 0.672 —­ —­ translation of the TFI contained no unclear items. The questionnaire
daily life due to a lack of strength
took less than 15 min to complete and was equivalent to reviewing
in your hands? (Q17)
other frailty questionnaires (Dent et al., 2016; Gobbens et al., 2012).
Do you experience problems in 0.560 —­ —­
your daily life due to physical This questionnaire has good face and content validity, internal con-
tiredness? (Q18) sistency and reliability. Following Polit and Beck (2021) recommen-
Do you have problems with your —­ 0.535 —­ dations, we tested content validity, which is not commonly used but
memory? (Q19) recommended for the survey's psychometric testing and cultural
Have you felt down during the last —­ 0.734 —­ adaptations. Content validity indicates the adequacy of the TFI-­SI
month? (Q20) questionnaire. The same applies to the content validity of each item.
Have you felt nervous or anxious —­ 0.781 —­ The content and face validity of TFI-­SI were found to be adequate.
during the last month? (Q21) We confirm the adequacy of the TFI-­SI questionnaire psychometric
Are you able to cope with problems —­ 0.771 —­ validation procedure based on our reliability and validity results.
well? (Q22)
The internal consistency of the TFI-­SI assessed among older peo-
Do you live alone? (Q23) —­ —­ 0.823 ple was adequate (α = 0.79). Gobbens and Uchmanowicz (2021) found
Do you sometimes miss having —­ —­ 0.595 that Cronbach's alpha of the TFI was between 0.66 and 0.80. Further-
people around you? (Q24)
more, other researchers reported Cronbach's alpha of frailty physi-
Do you receive enough support from —­ —­ 0.739
cal, psychological and So, ranging between 0.57 and 0.79 (Mulasso
other people? (Q25)
et al., 2016; Santiago et al., 2018), 0.37 and 0.63 (Gobbens et al., 2010;
Total variance explained (%) 41.3 16.3 8.0
Uchmanowicz et al., 2016), and 0.25 and 0.59 (Dong et al., 2017; Uch-
Cronbach's α 0.90 (each factor) 0.84 0.60 0.57
manowicz et al., 2016). We found that Cronbach's alpha for physical

KMETEC et al.
frailty was 088, psychological frailty was 0.59, and social frailty was
0.52, which is in line with or higher (e.g. for psychological frailty) than
in previous studies. Our study complements existing research by a
scale for frailty's physical, social and Ps among older people living in
nursing homes and community dwelling in Slovenia.
The corrected item-­total correlation of the TFI-­SI met the re-
quired criterion of 0.2 < r < 0.3. The internal consistency of our Ps
increased slightly (0.80) when eliminating one item (3rd) with a small
item-­total correlation (r < 0.13). The third component had the lowest
correlations with the total score among older people in community
dwelling (its removal increased to α = 0.81) and for older people liv-
ing in nursing homes (its removal increased to α = 0.76). The results
suggest that the TFI-­SI demonstrates reasonable internal consis-
tency among older people.
We found that the average TFI score was 7.02 ± 3.15 (in com-
munity dwelling, 6.39 ± 3.23; in nursing homes, 7.98 ± 2.76).
Compared with results from a study conducted in five European
countries and including healthy older adults in community dwell-
ing, our results indicate higher mean scores in frailty (6.39 ± 3.23)
than found in Greece (5.80 ± 3.09), Spain (4.64 ± 2.88), the Nether-
lands (4.25 ± 3.01) and the UK (4.47 ± 2.01) and a lower score only
according to Croatia (6.92 ± 3.20) (Zhang et al., 2020). In Brazil, the
mean score of the TFI for older adults aged 60 years and more was
4.40 ± 3.0, and frailty prevalence was 44.2% (Santiago et al., 2018).
In our study, the prevalence of frailty was 45% among older peo-
ple >65 years old living in nursing homes and community dwelling,
which is comparable with the studies which involved older people
aged 60 years or more residing in community dwelling in Brazil
(44.2%) (Santiago et al., 2018), but not with the results from China
(17.2%) (Dong et al., 2017) and UK (14%) (Gale et al., 2015). One
meta-­analysis (O'Caoimh et al., 2021) found that the prevalence
in older people living in the community was 12% and 45%, and an
overall estimate for pre-­frailty was 46% (45%–­48%). In our study,
the frailty prevalence was 36% of older people living in community
dwelling and 59% of older people living in nursing homes.
TFI includes the physical, social and Ps of frailty (Gobbens
et al., 2010). Therefore, the questionnaire is crucial and applicable
to studying frailty in nursing homes and community-­dwelling older
people. To assess frailty in older people accurately, it was crucial to
undertake psychometric validation of TFI-­SI questionnaires.
4.1 | Strengths and limitations
One strength of the study is its inclusion of older adults from both
community and nursing home settings. Gobbens and Uchmano-
wicz (2021) found in their review that only one study validated the
questionnaire in older people, among which two included older peo-
ple who do not live in the community dwelling. One study included
older people admitted to the hospital (Gobbens & Andreasen, 2020),
and the other included older people living in assisted living facilities
(Gobbens & van Assen, 2014). This study shows that a TFI-­SI ques-
tionnaire helps assess frailty in older adults. The questionnaire items
|
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7
are easily understood and answered by older people in nursing homes
or community dwelling. Due to its simplicity, the questionnaire can
assess the frailty of older people in various settings. It can help car-
egivers develop a quality approach to identifying and reducing frailty.
This study further supports the content validity and internal re-
liability of the TFI-­SI; however, due to some limitations of the study,
they should be interpreted with caution, as the study does not pro-
vide additional information about health status, pharmacotherapy
and other interventions for older adults. In addition, the study's
results may be specific to the gender of women. In the data anal-
ysis, we did not include the characteristics of those who produced
incomplete questionnaires. Due to the higher number of distributed
questionnaires and the number of researchers involved, we do not
have the information about the reasons for not returning. We also
recognize that 3 months may be a long time to retest, as we did, be-
cause participants' views may change. Another limitation is that we
could not ensure the same participant for the retest; however, we
used the same inclusion criteria and survey location to match the
two-­time data sets. Finally, one of the limitations is also using the
same sample for content and face validity. Notwithstanding certain
limitations, we have shown the questionnaire is essential and suit-
able for investigating frailty in nursing homes and community dwell-
ing where older people live.
5 | CO N C LU S I O N
Although frailty is not an expected part of primary ageing, it is fre-
quently overlooked, particularly in long-­term care. However, studies
monitoring fragility often indicate that the prevalence of this poten-
tially treatable condition is high in older adults, adversely affecting
the overall quality of life. Psychometrically validated tools are most
important in assessing the general, more ageing adult population's
frailty. The study has demonstrated that the TFI-­SI questionnaire is
an uncomplicated instrument with good psychometric properties in
the older population.
Continuous monitoring of frailty in clinical practice can enable
healthcare professionals to identify and manage the condition early.
Understanding how social, environmental and biological factors in-
fluence frailty and ongoing monitoring of frailty can help prevent the
negative health consequences of frailty and develop strategies for
better health care in old age and early life.
F U N D I N G I N FO R M AT I O N
A study reported in this publication was supported by the Slove-
nian Research Agency (BI-­US/22-­24-­096) and the National Cancer
Institute of the National Institutes of Health under Award Number
R01CA194178. The content is solely the responsibility of the au-
thors and does not necessarily represent the official views of the
National Institutes of Health.
C O N F L I C T O F I N T E R E S T S TAT E M E N T
All authors declare no conflict of interests.
 |
8 KMETEC et al.
PEER REVIEW
The peer review history for this article is available at https://
www.webof​s cien​ce.com/api/gatew​ay/wos/peer-­revie​w/10.1111/
jan.15898.
DATA AVA I L A B I L I T Y S TAT E M E N T
Data available on request due to privacy/ethical restrictions.
E T H I C S S TAT E M E N T
The research includes human data, which have been performed fol-
lowing the Declaration of Helsinki and have been approved by the
Ethics Committee (038/2018/2510-­1/504).
ORCID
Sergej Kmetec https://orcid.org/0000-0002-5601-0940
Zvonka Fekonja https://orcid.org/0000-0002-4224-8843
Adam Davey https://orcid.org/0000-0002-0796-2283
Nataša Mlinar Reljić https://orcid.org/0000-0003-1148-0831
Brendan McCormack https://orcid.org/0000-0001-8525-8905
Mateja Lorber https://orcid.org/0000-0001-7200-5204
T WITTER
Sergej Kmetec sergej_kmetec
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S U P P O R T I N G I N FO R M AT I O N
Additional supporting information can be found online in the
Supporting Information section at the end of this article.
How to cite this article: Kmetec, S., Fekonja, Z., Davey, A.,
Kegl, B., Mori, J., Reljić, N. M., McCormack, B., & Lorber, M.
(2023). Frailty in community-­dwelling older people and
nursing home residents: An adaptation and validation study.
Journal of Advanced Nursing, 00, 1–9. https://doi.
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