Introduction
Self-neglect in old age, as a hidden but pervasive phenomenon, refers to the individual’s ignorance or neglect to perform daily living activities, which can have negative consequences on daily life, health and safety of the person and even on his/her relationship with others. Identifying self-neglect requires the use of a standardized and dynamic tool with a holistic perspective. Considering the existing gap in the study of self-neglect in Iranian older adults and the need to identify this phenomenon during the provision of elderly care and the lack of a local appropriate tool for its measurement, the present study aims to investigate the psychometric properties of the Persian version of Mardan’s 18-item elder self-neglect (ESN) scale for Iranian older adults.

Methods
This is a descriptive cross-sectional and psychometrics study. Participants were selected from among the elderly people ≥60 years old who were members of retirement centers in Tehran, Iran. There were 30 volunteers in the preliminary phase of the study and 207 in the main phase. After translating and using the opinions of a panel of experts and removing one item (not compatible with Iranian culture), the psychometric properties of the 17-item ESN scale were evaluated in terms of face and content validity. Internal consistency was measured with Cronbach’s α, and the test re-test reliability was assessed using the intra-class correlation coefficient (ICC) with a 2-3 week interval. Before factor analysis, Keyser-Meyer-Elkin (KMO), Bartlett’s test, principal components analysis, and varimax rotation were performed. Data were statistically analyzed using SPSS software, version 21. 

Results
The age range of the participants was 60-95 years (mean age: 69 years). In terms of education, most of them (33%) had a bachelor’s degree. The mean score of SSS was 26.93±9.46. Eighty percent of the elderly had low self-neglect, and only 20% had a score higher than the average of severe self-neglect. The content validity index of the Persian ESN scale was 0.92. The KMO index was 0.837, which is above the acceptable level of 0.7. Bartlett’s test statistic was 971.408 (P<0.001). These results confirmed the implementation of factor analysis based on the correlation matrix. The results of the factor analysis identified four factors with a value above 1, which explained 53% of the total variance, and all were accepted. The factor of psychological self-neglect with the highest variance of 29.5 indicated its importance in the occurrence of self-neglect in the elderly. The Cronbach’s α values for the subscales are presented in Table 1. The ICC was 0.998 (P<0.001), indicating the acceptable test re-test reliability. The cut-off point was determined at 5.



Conclusion
The results confirmed the validity and reliability of the Persian version of the ESN scale for the Iranian elderly. The construct validity showed a 17-item factor-factor structure with acceptable internal consistency and test re-test reliability. This tool has been designed based on the biopsychosocial model, which makes it different from existing tools. The participants in this study were retired older people in Tehran. It is recommended to implement it in other cities with a large sample size. The tool can be used by geriatricians, nurses or medical staff for screening the elderly’s self-neglect.

Ethical Considerations

Compliance with ethical guidelines
This study was approved by the University of Social Welfare and Rehabilitation Sciences (Code: IR.USWR.REC.1399.196).

Funding
This study was financially supported by the University of Social Welfare and Rehabilitation Sciences.

Authors' contributions
All authors equally contributed to preparing this paper.

Conflicts of interest
The authors declared no conflicts of interest. 

Acknowledgements
The authors are extremely grateful to the University of Social Welfare and Rehabilitation Sciences for the financial assistance, and to the dear retirees of Tehran Retirement Centers and the respected manager and all the dear ones who somehow cooperated in carrying out the project.


 

1. American Public Welfare Association. The national elder abuse incidence study. Kansas: American Public Welfare Association; 1998. [Link]
2. Mardan H, Jaehnichen G, Hamid TA. Is self neglect associated with the emotional and financial abuse in community-dueling. IOSR Journal of Nursing and Health Science. 2014; 3(3):51-6. [DOI:10.9790/1959-03345156]
3. Mardan H, Hamid T, Redzuan M, Ibrahim R. Correlate of self-care and self-neglect among community-dwelling older adults. Iranian Journal of Nursing and Midwifery Research. 2014; 19(7 Suppl 1):S71-6. [PMID] [PMCID]
4. Johannesen M, LoGiudice D. Elder abuse: A systematic review of risk factors in community-dwelling elders. Age and Ageing. 2013; 42(3):292-8. [DOI:10.1093/ageing/afs195] [PMID]
5. Day MR, Mulcahy H, Leahy-Warren P, Downey J. Self-neglect: A case study and implications for clinical practice. British Journal of Community Nursing. 2015; 20(3):110, 112-5. [DOI:10.12968/bjcn.2015.20.3.110] [PMID]
6. Mardan H. prevalence and risk factors of self-neglect among older adults [PhD thesis]. Serdang: University of UPM; 2016. [Link]
7. Lee M, Kim K. Prevalence and risk factors for self-neglect among older adults living alone in South Korea. International Journal of Aging & Human Development. 2014; 78(2):115-31. [DOI:10.2190/AG.78.2.b] [PMID]
8. Mohseni M, Rashedi V, Iranpour A, Naghibzadeh Tahami A, Borhaninejad V. Prevalence of elder abuse and associated factors among community-dwelling older adults in Iran. Journal of Elder Abuse & Neglect. 2019; 31(4-5):363-72. [DOI:10.1080/08946566.2019.1682739] [PMID]
9. Teaster PB, Dugar TA, Mendiondo MS, Abner EL, Cecil KA, Otto JM. The 2004 survey of state adult protective services: Abuse of adults 60 years of age and older. Washington: The National Center on Elder Abuse; 2010. [Link]
10. Dyer CB, Goodwin JS, Pickens-Pace S, Burnett J, Kelly PA. Self-neglect among the elderly: A model based on more than 500 patients seen by a geriatric medicine team. American Journal of Public Health. 2007; 97(9):1671-6. [DOI:10.2105/AJPH.2006.097113] [PMID] [PMCID]
11. Cannell B, Livingston M, Burnett J, Parayil M, Reingle Gonzalez JM. Evaluation of the detection of elder mistreatment through emergency care technicians project screening tool. JAMA Network Open. 2020; 3(5):e204099. [DOI:10.1001/jamanetworkopen.2020.4099] [PMID] [PMCID]
12. Iris M, Conrad KJ, Ridings J. Observational measure of elder self-neglect. Journal of Elder Abuse & Neglect. 2014; 26(4):365-97. [DOI:10.1080/08946566.2013.801818] [PMID]
13. Dyer CB, Kelly PA, Pavlik VN, Lee J, Doody RS, Regev T, et al. The making of a self-neglect severity scale. Journal of Elder Abuse & Neglect. 2006; 18(4):13-23. [PMID]
14. Kelly PA, Dyer CB, Pavlik V, Doody R, Jogerst G. Exploring self-neglect in older adults: Preliminary findings of the self-neglect severity scale and next steps. Journal of the American Geriatrics Society. 2008; 56(Suppl 2):S253-60. [DOI:10.1111/j.1532-5415.2008.01977.x] [PMID] [PMCID]
15. Conrad KJ, Liu PJ, Iris M. Examining the role of substance abuse in elder mistreatment: Results from mistreatment investigations. Journal of Interpersonal Violence. 2019; 34(2):366-91. [DOI:10.1177/0886260516640782] [PMID]
16. Gibbons S, Lauder W, Ludwick R. Self-neglect: A proposed new NANDA diagnosis. International Journal of Nursing Terminologies and Classifications. 2006; 17(1):10-8. [DOI:10.1111/j.1744-618X.2006.00018.x] [PMID]
17. Iris M, Ridings JW, Conrad KJ. The development of a conceptual model for understanding elder self-neglect. The Gerontologist. 2010; 50(3):303-15. [DOI:10.1093/geront/gnp125] [PMID]
18. Dong XQ, Simon M, Evans D. Cross-sectional study of the characteristics of reported elder self-neglect in a community-dwelling population: Findings from a population-based cohort. Gerontology. 2010; 56(3):325-34. [DOI:10.1159/000243164] [PMID] [PMCID]
19. Wu M, Peng C, Chen Y, Yuan M, Zhao M, Wang C, et al. Nurses' perceptions of factors influencing elder self-neglect: A qualitative study. Asian Nursing Research. 2020; 14(3):137-43. [DOI:10.1016/j.anr.2020.05.001] [PMID]
20. Mardan H, Hamid A. Cross-sectional study of association between life satisfaction and self neglect in a community-dwelling elder population. Gerontologist. 2013; 53:546. [Link]
21. Pavlou MP, Lachs MS. Self-neglect in older adults: A primer for clinicians. Journal of General Internal Medicine. 2008; 23(11):1841-6. [DOI:10.1007/s11606-008-0717-7] [PMID] [PMCID]
22. Naik AD, Lai JM, Kunik ME, Dyer CB. Assessing capacity in suspected cases of self-neglect. Geriatrics. 2008; 63(2):24-31. [PMID] [PMCID]
23. Payne BK, Gainey RR. Differentiating self-neglect as a type of elder mistreatment: How do these cases compare to traditional types of elder mistreatment? Journal of Elder Abuse & Neglect. 2005; 17(1):21-36. [DOI:10.1300/J084v17n01_02] [PMID]
24. Dong X, Simon MA, Fulmer T, Mendes de Leon CF, Hebert LE, Beck T, et al. A prospective population-based study of differences in elder self-neglect and mortality between black and white older adults. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences. 2011; 66(6):695-704. [DOI:10.1093/gerona/glr053] [PMID] [PMCID]
25. Day MR, Leahy-Warren P, McCarthy G. Perceptions and views of self-neglect: A client-centered perspective. Journal of Elder Abuse & Neglect. 2013; 25(1):76-94. [DOI:10.1080/08946566.2012.712864] [PMID]
26. Paveza G, Vandeweerd C, Laumann E. Elder self-neglect: A discussion of a social typology. Journal of the American Geriatrics Society. 2008; 56(Suppl 2):S271-5. [DOI:10.1111/j.1532-5415.2008.01980.x] [PMID]
27. Bandura A. Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review. 1977; 84(2):191-215. [DOI:10.1037//0033-295X.84.2.191] [PMID]
28. Gibbons R, Jerusalem M. Generalized Self-Efficacy scale. In: Weinman J, Wright S, Johnston M editors. Measures in health psychology: A user’s portfolio causal and control beliefs windsor. Lancashire: Nelson; 1995. [Link]
29. Schwarzer R. Stress and coping from a social-cognitive perspective. Annals of the New York Academy of Sciences. 1998; 851:531-7. [DOI:10.1111/j.1749-6632.1998.tb09032.x] [PMID]
30. Schwarzer R, Jerusalem M. General self-efficacy scale. In: Johnston M, Wright S, Weinman J, editors. Measures in health psychology: A user’s portfolio. Heslington: NFER-NELSON; 1995. [Link]
31. Pallant J. SPSS survival manual: A step by step guide to data analysis using IBM SPSS. New York: McGraw-Hill Education; 2020. [Link]
32. Cochran WG. Sampling techniques. New York: Wiley; 1963. [Link]
33. Cohen C, Pereira F, Kampel T, Bélanger L. Understanding the integration of family caregivers in delirium prevention care for hospitalized older adults: A case study protocol. Journal of Advanced Nursing. 2019; 75(8):1782-91. [DOI:10.1111/jan.14009] [PMID]
34. DeVellis RF. Scale development: Theory and applications. Los Angeles: SAGE; 2012. [Link]
35. Wang JJ, Tseng HF, Chen KM. Development and testing of screening indicators for psychological abuse of older people. Archives of Psychiatric Nursing. 2007; 21(1):40-7. [DOI:10.1016/j.apnu.2006.09.004] [PMID]
36. de Boer MR, Moll AC, de Vet HC, Terwee CB, Völker-Dieben HJ, van Rens GH. Psychometric properties of vision-related quality of life questionnaires: A systematic review. Ophthalmic & Physiological Optics. 2004; 24(4):257-73. [DOI:10.1111/j.1475-1313.2004.00187.x] [PMID]