Testing and comparing two self-care-related instruments among older Chinese adults
Testing and comparing two self-care-related instruments among older Chinese adults
Lina Guo 0 1
Ulrika SoÈ derhamn 1
Jacqueline McCallum 1
Xianfei Ding 1
Han Gao 1
Qiyun Guo 1
Kun Liu 1
Yanjin Liu 1
0 Department of Neurology, the first Affiliated Hospital of Zhengzhou University , Zhengzhou, Henan , People's Republic of China, 2 Faculty of Health and Sport Sciences, Department of Health and Nursing Sciences, University of Agder, Grimstad, Aust-Agder, Southern Norway, 3 School of Health and Life Sciences, Department of Nursing & Community Health, Glasgow Caledonian University , Glasgow, Scotland , United Kingdom , 4 Department of Integrated ICU, the first Affiliated Hospital of Zhengzhou University , Zhengzhou, Henan , People's Republic of China, 5 School of Nursing, Jinzhou Medical University , Jinzhou, Liaoning , People's Republic of China, 6 Department of Nursing, the first Affiliated Hospital of Zhengzhou University , Zhengzhou, Henan , People's Republic of China
1 Editor: Daniel Serrani Azcurra, Universidad Maimonides Facultad de Ciencias de la Salud , ARGENTINA
Competing interests: The authors have declared
that no competing interests exist.
The study aimed to test and compare the reliability and validity, including sensitivity and specificity of the two self-care-related instruments, the Self-care Ability Scale for the Elderly (SASE), and the Appraisal of Self-care Agency Scale-Revised (ASAS-R), among older adults in the Chinese context.
A cross-sectional design was used to conduct this study. The sample consisted of 1152
older adults. Data were collected by a questionnaire including the Chinese version of SASE
(SASE-CHI), the Chinese version of ASAS-R (ASAS-R-CHI) and the Exercise of Self-Care
Agency scale (ESCA). Homogeneity and stability, content, construct and concurrent validity, and sensitivity and specificity were assessed.
The Cronbach's alpha (α) of SASE-CHI was 0.89, the item-to-total correlations ranged from
r = 0.15 to r = 0.81, and the test-retest correlation coefficient (intra-class correlation
coefficient, ICC) was 0.99 (95% CI, 0.99±1.00; P<0.001). The Cronbach's α of ASAS-R-CHI was
0.78, the item-to-total correlations ranged from r = 0.20 to r = 0.65, and the test-retest ICC
was 0.95 (95% CI, 0.92±0.96; P<0.001). The content validity index (CVI) of SASE-CHI and
ASAS-R-CHI was 0.96 and 0.97, respectively. The findings of exploratory and confirmatory
factor analyses (EFA and CFA) confirmed a good construct validity of SASE-CHI and
ASAS-R-CHI. The Pearson's rank correlation coefficients, as a measure of concurrent
validity, between total score of SASE-CHI and ESCA and ASAS-R-CHI and ESCA were
assessed to 0.65 (P<0.001) and 0.62 (P<0.001), respectively. Regarding ESCA as the
criterion, the area under the receiver operator characteristic (ROC) curve for the cut-point of
SASE-CHI and ASAS-R-CHI were 0.93 (95% CI, 0.91±0.94) and 0.83 (95% CI, 0.80±0.86),
There is no significant difference between the two instruments. Each has its own characteristics, but SASE-CHI is more suitable for older adults. The key point is that the users can choose the most appropriate scale according to the specific situation.
With the largest population in the world, as well as having the fastest population growth, it is
estimated that China's elderly population will reach more than 400 million by 2016. However,
China is a developing country, and the "no-rich aging first" condition has lead to an unsound
system of pension insurance, which causes stress for older adults [
With the development of the economy, and the transformation of society and its impact on
the change of family structure, the number of older adults who live alone or with a spouse is
rapidly increasing. The families of older adults who are single or live with a spouse account for
25% of all families, and it is predicted that this will increase to 90% by 2030 [
With the decline of physiological function, the morbidity rate of the older population is 3±5
times the rest of the population, particularly due to chronic diseases. These diseases result in
the decline of the physical and mental well-being of the elderly. This is occurring at the same
time as self-care is declining. Yet, older adults are wishing to live in their own homes if
possible. Therefore, the challenge which older adults face is not only disease and ill-health, but also
the problems the daily life causes [
The goal put forward in the field of public health in the 21st century is to achieve gradual
improvement of health in the aging population, including promotion of health, prevention of
disease, improving self-care facilities, whilst improving quality of life, and extending life
expectancy. The contradiction between "the healthy aging" and "the serious situation" gets more
pronounced with the rapid growth of the aging population, and the increasing number of older
adults who are alone or have diseases. All those have aroused widespread concern in society
]. This leads to the question of how the problems confronting older adults can be
addressed against this background?
Self-care can be defined as the practice of activities that individuals initiate on their own
behalf in maintaining health and well-being. Self-care refers to the ability of self-care
activities or self-management and it is influenced by many factors, such as age, level of
development, life experiences, cultural background, and health status. The self-care of individuals
can change depending on different development stages and different health conditions [
According to Sousa et al. [
] older adults through positive self-care can not only enhance
health-promoting behavior, but also improve the specific capability for those chronically ill
through self-management [
]. In addition, improving the self-management of older adults
can save national resources, help older adults to live up to their potential, improve the quality
of life and realize self-value. As a result, improving the ability of self-care of the older adults
is an important way to realize "healthy aging", and it is also a suitable model for the medical
services of China [
The progress of assessment tools regarding self-care ability is conducive to further
promotion of self-care. Correctly, evaluating the self-care ability of older adults is helpful to develop
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targeted measures to improve their self-care ability. This requires dedicated instruments to
measure the self-care ability of this special group. Currently, many scales are used to assess
the self-care ability of older adults, such as the Exercise of Self-care Agency scale (ESCA)
], the Appraisal of Self-care Agency Scale (ASAS) [
], the Self-care Ability Scale for
the Elderly (SASE) [
], Lorensen's Self-Care Ability Scale (LSCS) [
] and Elderly
People's Scale for Self-care Capacity Classifying (ESCC) [
]. The most widely used among
these instruments are the ASAS and its revised version, ASAS-R [13,21±25]. But at present,
only ESCA scale is commonly used to evaluate self-care ability of older adults in Mainland
To enrich and develop instruments for assessing self-care ability of the older adults in
China, we translated, according to recommend procedures [
], the ASAS-R and SASE into
Simplified Chinese, and made them more suitable for assessing self-care and self-care ability,
respectively, of older adults in China [
]. The Chinese version of SASE (SASE-CHI) [
and ASAS-R (ASAS-R-CHI) [
] have been confirmed as valid and reliable instruments, with
simple content, clear dimension and easy to understand. It is, however, of importance to
further test and compare the characteristics and the application effect of the two self-care
instruments to verify suitable instruments for use among older Chinese people.
Aim and objective
The study aimed to test and compare the reliability and validity, including sensitivity and
specificity of the two self-care-related instruments, the SASE, and the ASAS-R, among older adults
in the Chinese context.
A cross-sectional survey was conducted among older adults who were selected from the
community and hospitals in Jinzhou, a city in the northeast part of People's Republic of China.
This study was approved by the Ethical Review Board of Jinzhou Medical University, Jinzhou,
China. Written informed consent was obtained from all study participants after they received
information about the study and before the data collection interview took place [
The study sample consisted of 1152 older adults, from three districts and two hospitals in
Jinzhou city from April to October 2014. The inclusion criteria were: (1) 60 years old, (2)
able to communicate verbally in Chinese, (3) have no cognitive disorder ( 26 scores of the
Montreal Cognitive Assessment (MoCA). (MoCA is a quick and easy measure of cognitive
functioning that has been widely used to screen patients with mild cognitive impairments in
clinical evaluation and research. A higher score manifests a better cognitive function, and 26
scores indicate a normal cognition [
].), (4) willing to take part in the study, and (5) living in
Jinzhou more than six months.
The sample size of 1,152 older adults exceeded published criteria for psychometric analyses
such as 20:1 subjects to number of scale items ratio [
] or the specification of N >1,000 as
]. It reflects the thinking of Osborne and Costello [
] that in conducting
psychometric research, a large sample is required. In addition, recruitment of both
communitydwelling and hospitalized older adults was purposeful with the intention of obtaining a diverse
sample with chronic conditions.
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Prior to conducting the survey, a preliminary investigation was carried out amongst 100 older
adults (70 home-dwelling persons and 30 hospital patients), to identify any possible problems
in understanding the questions in the questionnaire.
Survey data were collected at community stations where older adults often held activities,
such as parks, squares, or venues where committee meetings took place. There were eight
community stations within three districts, the older adults came to these survey stations voluntarily
(n = 622). Hospital surveys were conducted in medical wards, geriatric wards, and
rehabilitation centers in two hospitals (n = 530).
Data were collected during one-to-one, face-to-face interviews with trained investigators
who assisted participants with completing the study questionnaire by presenting items in a
neutral, matter-of-fact way to avoid introducing response bias.
After two weeks of the investigation, 86 older adults (52 home-dwelling persons and 34
hospital patients) were randomly selected from the total participants with contact information, to
test the test-retest reliability.
The questionnaire included demographic variables such as age, gender, height, weight, body
mass index (BMI), marital status, educational level, alcohol drinking habits, smoking habits,
health insurance, and chronic diseases, contact information, and the three instruments
SASE-CHI, ASAS-R-CHI, and ESCA.
SASE-CHI. SoÈderhamn et al. [
] designed SASE in 1996. It is a five-point Likert scale
that consists of 17 items distributed on three factors, factor 1 (the repertoire, 8 items), factor 2
(the environment, 2 items), and factor 3 (the goals, 7 items). Four items are stated negatively.
Every item ranges from 5 to 1 between ªtotally agreeº to ªtotally disagreeº. The possible total
score ranges between 17 and 85. A higher total score indicates higher self-care ability. The
SASE has already been tested and used in Sweden and Norway [
ASAS-R-CHI. ASAS-R is the revised version of the ASAS. The ASAS was improved by
Evers and other scholars in 1986 [
], based on Orem's self-care deficit theory, with 24 items.
It emphasizes the ability of self-care behaviors, observation, judgment, decision-making and
implementation. This scale has been used and validated in several countries, including
America, the Netherlands, Norway, Switzerland, Mexico, and Hong Kong, China [
]. Despite its
widespread use, some authors have considered that the original version has a complex factor
structure and some items are not included in any factors [
]. Sousa et al. [
] have altered the
original version into ASAS-R, a 15-item, 3-factor version scale; factor 1 (having power for
selfcare, 6 items), factor 2 (developing power for self-care, 5 items) and factor 3 (lacking power for
self-care, 4 items) [
]. ASAS-R is a five-point Likert scale ranging from 1 to 5 between ªtotally
disagreeº and ªtotally agreeº. Four items are negatively expressed. A higher total score
indicates higher self-care ability, and maximum possible score is 75 [
]. The ASAS-R also has a
Brazilian version .
ESCA. The Americans Kearny and Fleischer [
] designed ESCA according to Orem's
selfcare deficit theory, in 1979. It was translated into Chinese and revised by Wang and Laffrey [
in 2000, with internal consistency estimates ranging from 0.86 to 0.92 and test-retest reliability
of 0.91 after one week [
]. Evidence for construct validity was demonstrated by significant
correlations in the expected directions with personal resources and perceived health [
]. The scale
is the most widely used measure in mainland China [36±38]. The Cronbach's α was 0.89 in the
present study. ESCA aims to assess the ability of the older adults with 43 items distributed on
four factors, factor 1 (motivation, 9 items), factor 2 (knowledge base, 9 items), factor 3 (active
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vs. passive response to situations, 12 items) and factor 4 (sense of self-worth, 13 items). The
total score of ESCA ranges from 0 to 172, the higher the score, the higher the self-care. If the
score is more than 66% of the total score ( 116points), it indicates a high level of self-care, and
less than 66% (<116 points) of the total score indicates a middle-low level [
The translation process of the SASE and ASAS-R into Simplified Chinese consisted of several
steps. (1) A bilingual professional translator translated the two scales from English into Chinese,
then another bilingual professional translator translated the translated Chinese versions back
into English. The two translators worked separately [
]. (2) A group of bilingual persons,
including three nursing experts and two psychology experts, examined the original English
versions and the back translated scales to resolve discrepancies in the meaning of the scale items
and to evaluate the cultural and the linguistic equivalence of each item. (3) A preliminary field
test was conducted among 10 older adults with the trial Chinese versions, and modifications
were made according to the participants' feedback on the items, until a consensus was reached
for the final SASE-CHI and ASAS-R-CHI in terms of wording, clarity, and cultural equivalence.
SPSS 21.0 and AMOS 17.0 were used to analyze the data. Cronbach's alpha (α) of the
SASE-CHI and ASAS-R-CHI, the Guttman Split-Coefficient, Cronbach's α of their respective factors
and item-to-total correlations (estimated by Pearson's rank correlation coefficients) were used
to test the homogeneity of the scales. The stability (test-retest reliability) of SASE-CHI and
ASAS-R-CHI was assessed by calculating two-way intra-class correlation coefficients (ICC) for
absolute agreement with 95% confidence intervals from 86 participants' two total scores of
SASE-CHI and ASAS-R-CHI, respectively.
To assess the content validity index (CVI) of ASAS-R-CHI and SASE-CHI, six specialists were
invited to assess content validity according to four levels; 4 = highly relevant, 3 = quite relevant,
2 = somewhat relevant, and 1 = not relevant. The ''highly relevant'' and "quite relevant" choices
yielded a score of 1, and "somewhat relevant " and "not relevant" choices yielded a score of 0.
Exploratory and confirmatory factor analyses (EFA and CFA) were used to examine the
construct validity of the SASE-CHI and ASAS-R-CHI, with the total sample randomly split
into two groups. One group of 576 participants was used to conduct the EFA, and the other
group of 576 was used for CFA.
Concurrent validity was estimated by Pearson's rank correlation coefficients between total
score of SASE-CHI and ESCA and their factors, and between total score of ASAS-R-CHI and
ESCA and their factors.
Receiver operator characteristic (ROC) curves, sensitivity, specificity, positive predictive
value (PPV) and negative predictive value (NPV), and the Youden's index were estimated to
find suitable cut-off points of SASE-CHI and ASAS-R-CHI, respectively. The ESCA was
regarded as the criterion. The total score 116 of ESCA indicates a high level of self-care; and
the total score <116 of ESCA indicates a middle-low level of self-care [
Considering ESCA as a good standard, 869 participants were defined with a middle-low level
of self-care, and 283 participants were defined with a high level of self-care. The characteristics
of the sample are presented in Table 1.
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Homogeneity. The Cronbach's α of SASE-CHI was 0.89, the Guttman Split-Coefficient of
SASE-CHI was 0.86, and the three factors of SASE-CHI yielded a Cronbach's α of 0.86, 0.71
and 0.80, respectively. The Cronbach's α of ASAS-R-CHI was 0.78, the Guttman
Split-Coefficient of ASAS-R-CHI was 0.72, and the three factors of ASAS-R-CHI yielded a Cronbach's α
of 0.77, 0.72 and 0.71, respectively.
There was no single item that if deleted would improve the overall Cronbach's α for
SASECHI (Table 2) or ASAS-R-CHI (Table 3). The item-to-total correlations of SASE-CHI ranged
between r = 0.15 and r = 0.81, where the average correlation was r = 0.59 (Table 2), and the
item-to-total correlations of ASAS-R-CHI ranged between r = 0.20 and r = 0.65, where the
average correlation was r = 0.50 (Table 3).
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Stability. The test-retest between the twice total score of SASE-CHI provided an ICC of
0.99 (95% CI, 0.99±1.00; P<0.001), and the test-retest between twice total score of
ASAS-R-CHI provided an ICC of 0.95 (95% CI, 0.92±0.96; P<0.001).
Content validity. The CVI, yielded a value of 0.96 for SASE-CHI, and a value of 0.97 for
Construct validity. The results of the EFA of SASE-CHI and ASAS-R-CHI indicated that
the Kaiser±Meyer±Olkin (KMO) were 0.84 and 0.81, and Bartlett's Test of Sphericity was
3383.60 and 2,845.70, respectively, with statistical significance (P<0.01). Three factors were
extracted with an eigenvalue greater than 1.00 of SASE-CHI (See Fig 1) and ASAS-R-CHI
(See Fig 2) after principal components analysis and Varimax orthogonal rotation. The three
extracted factors explained 72.65% and 64.93%, respectively, of the total variance of the two
scales. The CFA of SASE-CHI and ASAS-R-CHI indicated that all measurements of the
structural equation model were good fit (Table 4). Standardized three-factor structural model of
SASE-CHI appears in Fig 3 and the standardized three-factor structural model of ASAS-R-CHI
appears in Fig 4.
Concurrent validity. The Pearson's rank correlation coefficients between the total score
of SASE-CHI and ESCA and their factors showed that the two instruments were significantly
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Fig 1. Scree Plot of SASE-CHI (n = 576). Note. SASE-CHI: the Chinese version of Self-care Ability Scale for
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Fig 2. Scree Plot of ASAS-R-CHI (n = 576). Note. ASAS-R -CHI: the Chinese version of the revised form of
the Appraisal of Self-care Agency Scale.
correlated (P<0.01, r = 0.46 to 0.70). As well as ASAS-R-CHI and ESCA and their factors were
significantly correlated (P<0.01, r = 0.39 to 0.67). See Table 5.
Sensitivity and specificity. The result of the ROC curves showed that the area under the
ROC curve of SASE-CHI for the optimal cut-point was 0.93 (95% CI, 0.91±0.94), and the area
under the ROC curve of ASAS-R-CHI for the optimal cut-point was 0.83 (95% CI, 0.80±0.86).
The optimal cut-off point of ASAS-R-CHI was assessed to be 56 (indicating lower level of
self-care ability) and the optimal cut-off point of SASE-CHI was assessed to be 66 (indicating
lower level of self-care ability), based on the values for sensitivity, specificity, PPV, NPV,
Youden's index, and the ROC curves (Fig 5, Tables 6 and 7).
The participates in the sample came from the community and hospitals, with aspects such as
age, gender, occupation, and education background widely distributed. Thus, the sample had a
good representation, indicating a heterogeneous sample. The numbers of low educated and
smokers among the participants made it clear that the Chinese elderly in Jinzhou had a
relatively low education and relatively poor living habits. This may be due to the low-level
economy and society when they were young . Using ESCA as an assessment instrument, the
overall level of self-care of the older adults in Jinzhou was low, and the reason might be the
Note. x2/df, chi-square/degree of freedom; GFI, goodness of fitness index; AGFI, adjusted goodness of fit index; CFI, comparative fit index; TLI, Tucker
Lewis index, RMSEA, root mean square error of approximation; RMR, root mean residual; PCLOSE, P-value for test of close fit.
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Fig 3. Standardized three-factor structural model of the SASE-CHI (n = 576). Note. SASE-CHI: the
Chinese version of Self-care Ability Scale for the Elderly; Factor 1 (the repertoire, 8 items), Factor 2 (the
environment, 2 items) and Factor 3 (the goals, 7 items); S1-S17: Item 1-Item 17, and each item is explained in
Table 2. e1Ðe17: the measurement error of each observed variable to estimate latent variables.
failure in physiological function which is leading to the increase of chronic diseases (650 older
persons with chronic diseases) and thus the reduction in self-care .
The values of Cronbach's α, Guttman Split-Coefficients, and Cronbach's α of each factor of
the SASE-CHI ad ASAS-R-CHI were all within the recommended standard (>0.70) [
obtained item-to-total correlations were in agreement with the recommended standard [
Thus, the results showed that the two scales have good homogeneity [
]. The correlation
coefficients of the test-retest ICCs of SASE-CHI and ASAS-R-CHI evidenced that the two
instruments are stable. All these analyses showed that SASE-CHI and ASAS-R-CHI are credible
scales with a higher level of consistency and agreement compared to other studies of SASE and
ASAS-R [2,6,11,15±17,24,27], and SASE-CHI is slightly stronger than ASAS-R-CHI in the
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Fig 4. Standardized three-factor structural model of the ASAS-R-CHI (n = 576). Note. ASAS-R-CHI: the
Chinese version of the Appraisal of Self-Care Agency Scale-Revised; Factor 1 (having power for self-care, 6
items), Factor 2 (developing power for self-care, 5 items) and Factor 3 (lacking power for self-care, 4 items);
A1-A15: Item 1-Item 15, and each item is explained in Table 3. e1Ðe15: the measurement error of each
observed variable to estimate latent variables.
The CVI of ASAS-R-CHI and SASE-CHI exceeded 0.90, demonstrating a good content
], and the CVI of ASAS-R-CHI was slightly larger than the CVI of SASE-CHI. The
Pearson's rank correlation coefficients between SASE-CHI and ESCA ranged from 0.46 to
0.70, and the values between ASAS-R-CHI and ESCA ranged from 0.39 to 0.67, as measures of
concurrent validity. All correlations were significantly correlated, but the correlation
coefficient between SASE-CHI and ESCA was weaker compared to the correlation coefficient
between ASAS-R-CHI and ESCA.
Construct validity tested by EFA revealed three factors with an eigenvalue greater than 1.00
of SASE-CHI: the repertoire, 8 items; the environment, 2 items; and the goals, 7 items. The
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0.58※ 0.66※ Ð
SASE-CHI: the Chinese version of Self-care Ability Scale for the Elderly. S-F1, S-F2, and S-F3 are factor 1, factor 2 and factor 3 of SASE, respectively.
ASAS-R-CHI: the Chinese version of the revised form of the Appraisal of Self-care Agency Scale. A-F1, A-F2, and A-F3 are factor 1, factor 2 and factor 3 of
ESCA: the Exercise of Self-care Agency scale. E-F1, E-F2, E-F3, and E-F4 are factor 1, factor 2, factor 3 and factor 4 of ESCA, respectively.
Fig 5. The receiver operator characteristic (ROC) curve of the SASE-CHI and ASAS-R-CHI with ESCA
as a criterion (n = 1152). Note. SASE-CHI: the Chinese version of Self-care Ability Scale for the Elderly.
ASAS-R-CHI: the Chinese version of the revised form of the Appraisal of Self-care Agency Scale. ESCA: the
Exercise of Self-care Agency scale.
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SASE-CHI: the Chinese version of Self-care Ability Scale for the Elderly.
ESCA: the Exercise of Self-care Agency scale
findings are consistent with SoÈderhamn et al. [
] and Gao et al. [
]. The EFA of
ASASR-CHI also revealed three factors with an eigenvalue greater than 1.00: having power for
selfcare, 6 items; developing power for self-care, 5 items; and lacking power for self-care, 4 items.
This is consistent with Sousa et al. [
] and Guo et al. [
]. CFA was used to confirm the
construct validity of the SASE-CHI and ASAS-R-CHI, and the results showed that the factor
loadings and explained variances of the two self-care instruments were all strong and consistent
with the EFA, with the three-factor structure and good model fit indexes, yielding a good
construct validity of the two self-care scales. The CFA of SASE-CHI and ASAS-R-CHI in the
present study yielded a similar factor structure to the two previous studies [
The results of the ROC curves showed that the area under the ROC curve of SASE-CHI was
larger than ASAS-R-CHI in this study. The area under the curve can best represent the effect
of the scale's detection results, and it should be between 0.5 and 1.0. The higher the value, the
better the effect [
]. The reason that the effect of SASE-CHI was better than ASAS-R-CHI
could be twofold: first, SASE-CHI is a scale, developed especially for the older adults, while
ASAS-R-CHI is suitable for all adults. However, the present sample consisted of older adults.
Second, SASE-CHI is a self-reported scale, but ASAS-R-CHI can be used as a self-reported
scale or by health professionals for assessing self-care ability of their patients, and because of
this, different assessment methods may lead to different results [
A cut-off point is not evaluated for the American version of ASAS-R-CHI or the Brazil
version of ASAS-R [
]. Therefore, this study is the first to explore the cut-off point of
ASAS-R-CHI. The cut-off point of the Swedish version of SASE was 69 [
], and 71 for the
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ASAS-R-CHI: the Chinese version of the revised form of the Appraisal of Self-care Agency Scale. ESCA: the Exercise of Self-care Agency scale
Norwegian version of SASE [
]. The cut-off point of the Chinese version of the SASE was
lower than the cut-off points of the Swedish version and the Norwegian version of SASE. An
explanation could be that China is a developing country, therefore, the overall standard of
living of Chinese older adults is lower compared to older adults in European countries. Thereby,
the self-care level is also slightly lower than that of older adults in European countries, and the
cut-off point would be reduced naturally.
The ASAS-R-CHI, which can be used as a self-reported scale or for assessment by health
professionals, is suitable for all adults. It is based on Orem's self-care deficit theory, and it
focuses the assessment of personal self-care skills [
]. Nevertheless, SASE-CHI, a
selfreported scale particularly for older adults, is based on the theory of health and adaptation of
PoÈrn. This theory focuses on the assessment of self-awareness of individuals to their
environment, and self-care intentions and self-care skills in a certain environment . A self-report
instrument can assess the potential of self-care ability that others cannot evaluate, such as the
sense of self-care responsibility and self-concept. However, because of strong subjectivity, the
self-reported instrument may underestimate or overestimate the self-care ability of the
individual. So, when using self-reported scales, health professionals should observe daily behaviors of
the individuals. Assessment instruments are more objective, compared to the self-reported
scales, but are likely to ignore the individuals' initiative, that underestimate their self-care
]. Therefore, the instruments that can be used as both for self-reporting or assessment
are more reasonable [
This study has tested and compared the reliability and validity, sensitivity and specificity of
two self-care related instruments, providing a power for the development of self-care scales,
as well as a help for nurses to choose the appropriate scale for identifying and assessing older
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adults' self-care. The present study has some limitations, for example, the sample was limited
to one city, and it may have an influence on the result, so, a more diverse sample should be
included in follow-up studies. The one-to-one and face-to-face survey method resulted in a
high rate of response. This can also be a limitation, since the reserved personality of Chinese
people could lead them to not provide their true answers to an unfamiliar person. Therefore,
the level of self-care ability or self-care maybe was affected by this circumstance.
SASE-CHI and ASAS-R-CHI are homogenous and stable instruments for self-care evaluation
of older adults in hospitals and communities in China. However, further studies to test the
reliability, validity, sensitivity, and specificity in different geographical populations in China
should be performed. The two self-care instruments are equal, but with their own
characteristics. However, SASE-CHI is most suitable for older adults. Most important is that the user can
choose the best instrument according to the specific situation.
We express our gratitude to all the participants.
Conceptualization: Lina Guo, Xianfei Ding, Yanjin Liu.
Data curation: Lina Guo, Xianfei Ding, Yanjin Liu.
Formal analysis: Lina Guo, Xianfei Ding, Yanjin Liu.
Investigation: Lina Guo, Han Gao, Qiyun Guo.
Methodology: Lina Guo.
Project administration: Lina Guo, Kun Liu, Yanjin Liu.
Resources: Lina Guo.
Software: Lina Guo, Xianfei Ding, Qiyun Guo.
Supervision: Lina Guo, Jacqueline McCallum, Yanjin Liu.
Validation: Lina Guo, Jacqueline McCallum, Yanjin Liu.
Visualization: Lina Guo, Ulrika SoÈderhamn, Jacqueline McCallum, Yanjin Liu.
Writing ± original draft: Lina Guo.
Writing ± review & editing: Lina Guo, Ulrika SoÈderhamn, Jacqueline McCallum, Han Gao,
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