Prevalence of self-neglect and related factors among older adults living in Western Turkey: a cross-sectional study

Abstract

Background

Self-neglect is a serious public health problem affecting older people. This study was conducted to determine the prevalence of self-neglect and related factors in the elderly, which has become more important with the increase in the elderly population.

Methods

The cross-sectional study included individuals aged 65 years and over. Data were collected via face-to-face interviews using a questionnaire. The questionnaire content included questions related to sociodemographic and health-related characteristics, the Istanbul Medical School Elder Self-Neglect questionnaire, standardized Mini Mental State Examination, Geriatric Depression Scale: Short Form, and Katz Activities of Daily Living Scale. Factors associated with self-neglect were identified using logistic regression analysis.

Results

In this study, the prevalence of self-neglect in the elderly was 36.6%. In addition, living alone (OR: 2.71), low monthly income perception (OR: 1.86), poor/very poor health perception (OR: 2.30), having mild dementia (OR: 3.00), having severe dementia (OR: 4.54), being severely dependent (OR: 3.39) and lower levels of education (OR: 1.70) were found to be significant factors associated with self–neglect.

Conclusion

The results of this study showed that approximately one in three elderly people neglected themselves, and that some sociodemographic and health-related characteristics of the elderly were associated with self-neglect.

Background

Medical developments have significantly increased life expectancy at birth, and the aging of the population has brought important public health issues such as self-neglect to the agenda [1]. Self-neglect in the elderly is mostly defined as the inability of the elderly to meet needs such as adequate food, water, clothing, shelter, medicine and hygiene, as well as refusal of safety measures or failure in this regard [2]. Self-neglect is recognised as a globally widespread public health problem that threatens the health and safety of the elderly [3]. The results of a systematic review indicated that the prevalence of self-neglect in the elderly living in the community ranged from 18.4 to 29.1% [4]. Although few studies have been conducted in Turkey, İlhan et al. (2018), who conducted a study in Istanbul, reported that 16.8% of the elderly self-neglected [5]. However, it is estimated that the actual prevalence is much higher due to reasons such as self-neglect cases remaining hidden [6].

Self-neglect is a serious problem affecting older people with different conditions [7]. Although self-neglect is often associated with frailty, it is characterised by many problems that can be seen in physical, psychological and social areas [2]. These problems include cardiovascular and pulmonary diseases, depression, dementia, diabetes, stroke history and alcohol abuse [8]. In addition, in one study, it was found that self-neglect was associated with a significant increase in 1-year mortality risk [9].

The negative outcomes associated with self-neglect and its increasing prevalence indicate that self-neglect in older adults should be evaluated [5, 10]. Community health nurses play an important role in the identification, management and prevention of self-neglect [11]. Furthermore, although there has been a significant increase in the literature on self-neglect in the elderly in recent years, it is still insufficient [2]. Conducting studies to ascertain the magnitude of the problem is seen as an important step in determining the level of self-neglect of the elderly and planning appropriate interventions. In this context, the aim of this study was to determine the prevalence of self-neglect and related factors in the elderly.

Methods

Study design and participants

The population of the cross-sectional study consisted of 27,550 elderly people aged 65 years and over registered at family health centers living in the city of Kütahya, Turkey. Kütahya, a province in western Turkey, constitutes 1.5% of Türkiye’s land with a total surface area of ​​11,875 km². The Epi Info 7.2 program was used to calculate the sample size. The incidence rate value (p) and margin of error (d) of the variable of interest were taken as 0.05, 95.0%, and 0.05%, respectively. As a result of the calculation, the sample size was determined as 379. Based on a sample size of 380, the correlation value of the study was determined as 0.678 in the post hoc power analysis using the G*Power 3.1 program. In addition, the power of the study was calculated as 0.99 with a 5% margin of error for correlation analysis.

Data Collection: The data were collected by the researcher between March and October 2022 through face-to-face interviews by visiting the homes of elderly individuals registered in 3 family health centers located in Kütahya city centre. Simple random sampling method was used to determine the elderly to be included in the sample. The study was completed with 387 individuals who were 65 years and older, could read and write in Turkish, could answer the questions, and agreed to participate in the study voluntarily. It took an average of 20 min to complete the questionnaire (Fig. 1).

Fig. 1

Participant flow chart

Data collection tools

The questionnaire content included questions related to some sociodemographic and health-related characteristics of the elderly, the Istanbul Medical School Elder Self-Neglect (IMSelf-neglect) questionnaire, the Standardized Mini Mental State Examination, and the Geriatric Depression Scale Short Form.

Istanbul medical school elder self-neglect (IMSelf-neglect) questionnaire

The IMSelf-neglect questionnaire was developed by İlhan et al. (2018) to screen for self-neglect in the elderly living in the community [5]. It comprises 11 items related to personal hygiene, health habits, and social functioning. The total test score is the sum of ‘yes’ answers, each with 1 point, and the total test score ranges from 0 to 11 points. A score of 7 and below reflects self-neglect, with lower test scores indicating a higher likelihood of self-neglect. It was reported that the Cronbach’s alpha value of the scale was 0.708, and in the reliability analysis performed in this study, the Cronbach’s alpha value was 0.789, and the intraclass correlation coefficient value was 0.781.

Standardized mini mental state examination (S-MMSE)

The Turkish validity and reliability study of the test developed by Folstein et al. (1975) was conducted by Güngen et al. (2002). The test evaluates attention and orientation, memory, calculation, recall, and language. In Turkey, the cut-off score for mild to moderate dementia is 23/24 [12].

Geriatric depression scale short form

The Turkish validity and reliability study of the scale developed by Yesavage and Sheikh (1986) was conducted by Durmaz et al. (2018). The 15-item scale asks yes/no questions about emotions in the last week. A total score of 5 or less is considered as no depression, 5–8 as mild depression, 9–11 as moderate depression, and 12–15 as severe depression [13].

Katz activities of daily living (ADL) scale

This scale was developed in 1963 by Katz et al. The study of the validity and reliability of the ADL index in Turkey was conducted by Pehlivanoğlu et al. (2018). The Katz ADL Scale comprises six questions including information about bathing, dressing, toileting, movement, excretion, and nutrition activities. Accordingly, individuals are evaluated as dependent with 0–6 points, semi-dependent with 7–12 points, and independent with 13–18 points in the ADL index. The Cronbach’s alpha coefficient of the scale was determined as 0.83 [14].

Variables

Dependent variable

The dependent variable is self-neglect.

Independent variables

Relevant literature was used to determine the independent variables [4, 5, 15, 16]. Independent variables were age, gender, marital status, presence of children, cohabitant, educational level, employment status, monthly income perception, smoking, alcohol use, general health perception, presence of chronic diseases, use of prescription drugs, mental status, physical dependency status, and presence of depression.

Data analysis

Data were analysed using the SPSS version 27 for Windows. To analyse the data, descriptive statistical methods (number, percentage), an independent t-test and a chi-square test were used (p < 0.05). Variables that were found to be significant in the nonparametric analyses were included in the logistic regression analysis. Statistical significance was set at an α level of 0.05.

Ethical considerations

Approval was obtained from Ethics Committee of the Çanakkale Onsekiz Mart University (2022-YONP-0216). In addition, written consent was obtained from the participants through an informed consent form describing the study.

Results

The mean age of the elderly people was 71.29 ± 6.32 years. In addition, 54.5% were female, and 26.3% were living alone. Furthermore, 12.4% were smokers, and 5.8% used alcohol. Additionally, 58.7% perceived their health status as good/very good, 54.5% had at least one chronic disease, 54.5% used at least one prescription drug, and 83.4% used their prescription drugs regularly.

Table 1 reports the relationship between some descriptive and health status characteristics of the elderly and self-neglect. The results of the univariate regression analysis indicated that there was a statistically significant relationship between the elderly’s cohabitant status, educational level, monthly income perception, general health perception, presence of chronic disease, prescription drug use, S-MMSE and Katz ADL Scale results and self-neglect (p < 0.05).

Table 1 The relationship between some descriptive and health status characteristics of the elderly and self-neglect (n = 380)

The findings of the geriatric assessment tests such as the S-MMSE, Katz ADL Scale and Geriatric Depression Scale: Short Form are presented in Table 2. According to the results, 39.2% of the elderly had mild to severe dementia, and 48.4% had mild to severe depression. In addition, according to the KATZ ADL Scale, 17.1% of the elderly were found to be moderately and severely dependent.

Table 2 Some descriptive statistics of the scales (n = 380)

In this study, the prevalence of self-neglect in the elderly was 36.6% (n = 139). Table 3 shows the percentages of the participants’ responses to each item in the IMSelf-neglect scale. According to the table, among all the forms of self-neglect listed in the scale, the items to which the participants answered ‘no’ the most were ‘Participating in artistic activities, such as cinema, theatre, concerts’, ‘Doing activities that protect my physical health, such as walking and exercising’, and ‘Having a pastime, such as solving puzzles, reading books, knitting’.

Table 3 Distribution of participants’ responses to the items in the IMSelf-neglect scale

For multivariate regression analysis, associated factors (p < 0.05) identified in previous analyzes were added to the logistic regression analysis. Based on the logistic regression analysis, living alone (OR: 2.71), low monthly income perception (OR: 1.86), poor/very poor health perception (OR: 2.30), having mild dementia (OR: 3.00), having severe dementia (OR: 4.54), being severely dependent (OR: 3.39) and lower levels of education (OR: 1.70) were found to be significant factors associated with self–neglect (Table 4).

Table 4 Logistic regression analysis of factors associated with self-neglect

Discussion

In this study investigating self-neglect and related factors in the elderly, the prevalence of self-neglect in the elderly was 36.6%. A systematic review of the results of 19 studies in the literature revealed that the prevalence of self-neglect in the elderly was between 18.4% and 29.1% [4]. In the elderly living in South Korea, the prevalence of self-neglect was reported as 22.8% [15]. Although few studies have been conducted in Turkey, in a study conducted in Istanbul by İlhan (2018), the prevalence of self-neglect in the elderly was found to be 16.8% [5]. The rates of self-neglect in this study seem to be higher than those in other studies, and the difference in the study results is striking. This may be due to the sociocultural characteristics of the sampled elderly or the difference in the instruments used to measure self-neglect. However, it has been emphasised in the literature that self-neglect is often hidden and underreported [16]. Therefore, prevalence rates may be much higher than stated. It is important for community health nurses to assess older people for self-neglect, as they are well placed to manage this problem [17]. However, adequate training for health professionals is vital to help them recognise the phenomenon of self-neglect [18]. Therefore, undergraduate, and graduate core education curricula could include courses on self-neglect to increase the knowledge and raise the awareness of community health nurses about the subject [10].

Considering the prevalence of self-neglect, public health measures should be taken to protect elderly individuals. Primary, secondary and tertiary prevention steps of public health can be followed to protect elderly individuals from self-neglect. Primary prevention aims to eliminate possible risk factors [1]. In this study, some results considered to be related to self-neglect in the elderly were obtained. The first of these was living alone. According to the study results, 2.7 times more self-neglect was seen in those living alone. Similarly, it was highlighted in the literature that more self-neglect was seen in those living alone [15, 19] and suggested that an integrated prevention and intervention program should be developed to protect the elderly living alone from self-neglect [15].

Another variable associated with self-neglect in this study was the perception of monthly income. In a study conducted in South Korea, it was found to have a strong negative relationship with self-neglect [15]. The risk of self-neglect may decrease for elderly people with higher monthly income, as they have more opportunities to receive health services and to participate in more social activities [4]. In the current study, it was determined that self-neglect was 2.3 times higher in those with poor/very poor general health perception. Similarly, Dong et al. (2012) reported that the prevalence of self-neglect increased as the health status of the elderly worsened [16]. Since self-neglect can cause significant health consequences in the elderly population, it is expected that the perception of the health status of self-neglecting individuals will deteriorate.

Cognitive impairment is seen as the most important predisposing factor for self-neglect in the elderly population [20]. In this study, those with dementia were 3-4.5 times more likely to self-neglect. In a cohort of elderly people, it was found that individuals with dementia were four times more likely to self-neglect during a nine-year follow-up period [19]. In another study, it was reported that older adults with lower levels of cognitive health were more likely to self-neglect [21]. Another variable associated with self-neglect in the current study was dependence on activities of daily living. Studies in the literature have drawn attention to the relationship between self-neglect and decreased functionality [5, 22, 23]. Lower physical functioning can reduce the ability of older individuals to perform daily activities, which can lead to the inability to meet basic needs and self-neglectful behaviours [21]. In the study, it was determined that self-neglect was 1.7 times less common in those with an educational level of secondary school and above. Similarly, in the study conducted by Mardan et al. (2014) in Malaysia, the educational level of the elderly was found to be associated with self-neglect [24]. However, another study conducted in Turkey found that there was no relationship between educational level and self-neglect [5]. This may be due to other characteristics of the elderly in the sample.

This study is one of the few studies on self-neglect of the elderly in Turkey. In addition, collecting data in the environments where the elderly live and directly from the participants allowed us to obtain more reliable information. However, medical records of the participants could not be reviewed, so additional information about the medications used by the elderly could not be provided. However, the study has some limitations, the first of which is that the questionnaires were completed according to the elderly’s own statements. When answering the survey questions, the elderly may not have given a correct statement due to forgetfulness. Since the participants’ medical records could not be reviewed, sufficient data could not be provided about information such as the medications used by the elderly. Another limitation is that the study was conducted only with elderly people living in a city center. Therefore, the findings can only be generalized to the specified region. In addition, due to the cross-sectional design of the study, it is not possible to establish causal relationships. The findings should be interpreted in light of this information. Finally, there may be independent variables (such as social activity, social isolation) that could not be investigated in the study. It is recommended that future researchers include independent variables when evaluating self-neglect.