Concurrent validity of the CIQ for assessing social frailty among community-dwelling older adults

Concurrent validity of the CIQ for assessing social frailty among community-dwelling older adults | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Concurrent validity of the CIQ for assessing social frailty among community-dwelling older adults Shingo Koyama, Mizue Suzuki, Kohei Kawamura, Yota Kunieda This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5915848/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background/Purpose: The community integration questionnaire (CIQ) is one of the assessment tools used to evaluate the state of social participation. We aimed to determine whether or not the CIQ can estimate social frailty status defined by the social frailty screening index in community-dwelling older adults. Method: A cross-sectional study was performed in community-dwelling older adults aged 65 and above. We investigated the CIQ, and social frailty using the social frailty screening index. To assess the relationship between social frailty and the CIQ, we performed a partial correlation analysis and receiver operating characteristics curves. Results: One hundred and ninety-four participants were enrolled (mean age [standard deviation] was 76.3 [5.5] years). A partial correlation analysis showed that family integration ( r = 0.189) had a low positive correlation with the social frailty score. Social integration ( r = −0.209), productivity ( r = −0.417), the CIQ total score ( r = −0.204), and the combination of social integration and productivity ( r = −0.403) had a low to moderate positive correlation with the social frailty score. The cutoff values for estimating social frailty were 6/7 (AUC: 0.560) for home integration, 6/7 (AUC: 0.633) for social integration, 2/3 (AUC: 0.709) for productivity, 18/19 (AUC: 0.629) for the CIQ total score, and 11/12 (AUC: 0.721) for the combination of social integration and productivity. Conclusion and implications: These results suggest that the CIQ is a useful tool associated with social frailty. Community-dwelling older adults the community integration questionnaire social frailty social participation Figures Figure 1 Background Social frailty is a serious concern for aged societies because older adults face several social challenges in terms of family structure, economic status, and social participation. Social frailty has negative impacts on health-related outcomes such as physical and cognitive impairment, disability, and death (Ko & Lee, 2022 ; Makizako et al., 2015 ; Teo et al., 2017 ; Tsutsumimoto et al., 2017 ; Yamada & Arai, 2018 ). Therefore, it is necessary to promote social participation among older adults and carry out appropriate assessments for the prevention of and recovery from social frailty. There are several different assessment tools for social frailty. A systematic review and meta-analysis of the prevalence of social frailty presents three assessment tools that have been widely used to assess social frailty (Zhang et al., 2023 ). One of these three assessment tools, the social frailty screening index, can simply and quickly assess social frailty by answering four questions. In addition, since the question content is based on the concept of social frailty proposed by Bunt et al., ( 2017 ), the assessment results are easy to interpret. Therefore, this index is suitable for screening for social frailty. However, it is considered unsuitable for judging effectiveness of the prevention of and recovery from social frailty. This is because the social frailty screening index has a small number of items and contains factors that are difficult to change through intervention, such as family structure and economic conditions. The community integration questionnaire (CIQ) is one of the assessment tools used to evaluate the state of social participation. The CIQ was developed by Willer and colleagues to assess the handicap of patients with traumatic brain injury (Willer et al., 1993 ). Since its development, the CIQ has become one of the most widely used assessment tools to measure social participation among subjects. In recent years, the CIQ has been applied to nondisabled older adults (Segev-Jacubovski & Shapiro, 2022 ). Furthermore, the CIQ is a 15-item standardized self-report questionnaire on participation in social activities. Therefore, it may be able to capture changes in social activities more sensitively than the social frailty screening index. However, the relationship between social frailty and the CIQ in community-dwelling older adults is unclear. Assessing the risk of social frailty could be helpful with regard to the early interventions required to enhance social engagement. Thus, the aim of this study was to determine whether or not the CIQ can estimate social frailty status defined by the social frailty screening index in community-dwelling older adults. Methods Study design and participants This cross-sectional study was conducted on community-dwelling older adults in Tokyo, Japan between March and October 2021. Participants were recruited based on an advertisement released in the local press and posters displayed at the senior center. The inclusion criteria were individuals aged 65 and above, who had the ability to walk independently to participate in the health checkup and cooperate in the study. The exclusion criteria were individuals who received Japanese Long-Term Care Insurance (LTCI) services and those whose survey data were missing. Participants using the LTCI services are excluded because they have an aspect of enjoying social participation. This study was conducted in accordance with the guidelines proposed by the Declaration of Helsinki. The study protocol was reviewed and approved by the Ethics Committee of Juntendo Tokyo Koto Geriatric Medical Center (approval No. G20-0016). The community integration questionnaire We investigated social participation using the CIQ (Willer et al., 1993 ). It is a self-administered questionnaire consisting of 15 items and measures community integration based on 3 domains: home integration (e.g., meal preparation and housework), social integration (e.g., shopping, visiting friends, and leisure activities), and productivity (e.g., full vs part-time work, school, and volunteer activities). Most items are rated on a scale of 0–2, and the total score is calculated within a range of 0–29 points: home integration (10 points); social integration (12 points); productivity (7 points). A higher score represents greater independence and community integration. In this study, since we intended to investigate the reemployment situation of the subject after retirement, deleted the answer items for retirement due to age. Social frailty assessment We used a social frailty screening index proposed by Yamada and Arai (Yamada & Arai, 2018 ). This index is based on Bunt’s social frailty concept that considers general resources, social resources, social behaviors, and the fulfillment of basic social needs (Bunt et al., 2017 ). The question regarding general resources (financial difficulties) is, “Are you satisfied with your economic condition?” The answer choices include (a) very satisfied, (b) satisfied, (c) unsatisfied, and (d) very unsatisfied. “Poor general resources (1 point)” was operationally defined when the answer was (d). The question regarding social resources (living alone) is, “Do you live alone?.” “Poor social resources (1 point)” was defined as living alone. The question regarding social behavior (lack of social activity) is, “Which social activities do you participate in (multiple answers allowed)?.” The answer choices included (a) local festivals or events, (b) community activities in the neighborhood, (c) self- management groups, and (d) volunteer activities. “Poor social behavior (1 point)” was operationally defined as participating in none of these activities. The question regarding the fulfillment of basic social needs (influential contact with neighbors) is, “How do you get along with your neighbors?.” The answer choices included (a) I have a neighbor who visits each house, (b) I have a neighbor to chat with on the street, (c) I have a neighbor to say hello to, and (d) I do not communicate with neighbors. “Poor fulfillment of basic social needs (1 point)” was defined when the answer was (c) or (d). We defined a point of 2 or higher as social frailty, 1 as social prefrailty, and 0 as robustness according to a previous study (Yamada & Arai, 2018 ). Other variables We investigated age, sex, height, weight, body mass index, education history, comorbidities, and number of medications through the questionnaire. Additionally, handgrip strength and comfortable walking speed were evaluated as physical function, and Japanese version of Montreal Cognitive Assessment (MoCA-J) (Fujiwara et al., 2010 ) as cognitive function. Statistical analysis We compared all variables among the participants who were living alone and not living alone. The differences between the two groups were analyzed using the student’s t-test, Mann-Whitney U-test, and chi-squared test. A partial correlation analysis with adjustment for age and sex was performed to examine the correlation between the social frailty screening index and CIQ. The validity of the CIQ for estimating the social frailty status was evaluated using receiver operating characteristics curves. The cut-off value for the optimal estimation of social frailty was determined using the Youden Index. The data were analyzed using the SPSS software (version 28; IBM SPSS Japan, Tokyo, Japan). P < 0.05 was considered statistically significant for all analyses. Results Of the 236 participants who met the inclusion criteria, 42 were excluded as they had a certification for LTCI or missing survey data. A total of 194 participants were enrolled in this study. The characteristics of the participants are shown in Table 1. The mean age [standard deviation] was 76.3 [5.5] years, 165 participants (85.1%) were women, and the proportion of participants living alone was 44.8%. Significant differences were observed with respect to the sex, height, social frailty screening index, the CIQ total points, and home integration by the CIQ among the two groups (P < 0.01). The results of the partial correlation analysis are shown in the Fig. 1 . Family integration (r = 0.189, p = 0.006) had a low positive correlation with the social frailty score. Social integration (r = − 0.209, p = 0.004), productivity (r = − 0.417, p < 0.001), the CIQ total score (r = − 0.204, p = 0.005), and the combination of social integration and productivity (r = − 0.403, p < 0.001) had a low to moderate positive correlation with the social frailty score. Validity and cutoff point of the CIQ for the social frailty are shown in the Table 2. The cutoff values for estimating social frailty were 6/7 (AUC: 0.560, sensitivity: 80.0%, specificity: 36.9%) for home integration, 6/7 (AUC: 0.633, sensitivity: 74.8%, specificity: 46.2%) for social integration, 2/3 (AUC: 0.709, sensitivity: 78.6%, specificity: 60.4%) for productivity, 18/19 (AUC: 0.629, sensitivity: 49.5%, specificity: 71.4%) for the CIQ total score, and 11/12 (AUC: 0.721, sensitivity: 58.3%, specificity: 78.0%) for the combination of social integration and productivity. Discussion This study investigated the relationship between social frailty and the CIQ in community-dwelling older adults. The CIQ was significantly correlated with the social frailty screening index and showed moderate discrimination accuracy. Our findings suggest that the CIQ is a useful tool associated with social frailty. In each CIQ item, social integration and productivity were negatively correlated with social frailty, while home integration was positively correlated. A possible reason for home integration to be positively correlated is that the item of social frailty screening index includes living alone. In general, older adults who lead independent lives need to participate in daily activities at home by themselves. In fact, in this study, older adults living alone had significantly higher home integration than those not living alone. A previous study has shown that older adults living alone have more indoor activities than not living alone (Gagliardi et al., 2007 ). For these reasons, home integration may have been inversely correlated with the other items. Therefore, when determining social frailty using the CIQ, it is recommended to use a combination of social integration and productivity, which does not consider home integration while computing the total score. The combination of social integration and productivity had the highest discrimination accuracy among the variables examined in this study. However, it had moderate accuracy (AUC: 0.721). The possible reason may have been influenced by the components of social frailty. Bunt’s social frailty concept consists of four elements: general resources, social resources, social behavior, and the fulfillment of basic social needs (Bunt et al., 2017 ). The social frailty screening index used in this study includes these four elements. However, the CIQ only considers social behavior among the elements of this concept. Therefore, it is possible that the accuracy of determining social frailty using the CIQ remained moderate. Thus, when determining social frailty using the CIQ, it is necessary to consider resources such as family structure and economic situation. The strengths and limitations of this study are as follows. The strength of the present study is that it contributes toward the usefulness of the CIQ. The CIQ has more items than the social frailty screening index; the question content includes many controllable elements, such that it is easy to capture changes in social participation. Therefore, it may be useful not only for screening social frailty, but also for determining the effectiveness of the related interventions. A limitation of this study is that sex was not considered as a variable in the analysis. A previous study has shown that there are differences in social participation depending on an individual’s sex (Dahan-Oliel et al., 2008). This study had few male participants and could not be stratified by sex. Therefore, future studies are required to further investigate the different uses of the CIQ. Conclusions In conclusion, the CIQ was associated with social frailty in community-dwelling older adults. Furthermore, the combination of social integration and productivity had moderate discrimination accuracy. These results suggest that the CIQ might act as an assessment tool to estimate the risk of social frailty. Statements and Declarations Funding This Work was supported by JSPS KAKENHI Grant Number 22H04413, and Tokyo Physical Therapy Association Grant Number 2021004. Author Contribution S.K., M.S., K.K.,and Y.K. carried out the investigation. S.K. wrote the manuscript with support from M.S, K.K.. M.S. and K.K. helped supervise the project.S.K. and M.S. conceived the original idea. Y.K. supervised the project. Acknowledgement The authors acknowledge Mr Yudai Koiwa and Mr Daisuke Ishiyama for their contributions to the data collection. References Bunt, S., Steverink, N., Olthof, J., van der Schans, C. P., & Hobbelen, J. S. M. (2017). Social frailty in older adults: a scoping review. Eur J Ageing , 14 (3), 323-334. https://doi.org/10.1007/s10433-017-0414-7 Dahan-Oliel, N., Gelinas, I., & Mazer, B. (2008). Social Participation in the Elderly: What Does the Literature Tell Us?. 20 (2), 159-176. https://doi.org/10.1615/CritRevPhysRehabilMed.v20.i2.40 Fujiwara, Y., Suzuki, H., Yasunaga, M., Sugiyama, M., Ijuin, M., Sakuma, N., Inagaki, H., Iwasa, H., Ura, C., Yatomi, N., Ishii, K., Tokumaru, A. M., Homma, A., Nasreddine, Z., & Shinkai, S. (2010). Brief screening tool for mild cognitive impairment in older Japanese: validation of the Japanese version of the Montreal Cognitive Assessment. Geriatr Gerontol Int , 10 (3), 225-232. https://doi.org/10.1111/j.1447-0594.2010.00585.x Gagliardi, C., Spazzafumo, L., Marcellini, F., Mollenkopf, H., Ruoppila, I., Tacken, M., & Széman, Z. (2007). The outdoor mobility and leisure activities of older people in five European countries. Ageing and Society , 27 , 683-700. https://doi.org/10.1017/S0144686X07006198 Ko, Y., & Lee, K. (2022). Social Frailty and Health-Related Quality of Life in Community-Dwelling Older Adults. Int J Environ Res Public Health , 19 (9). https://doi.org/10.3390/ijerph19095659 Makizako, H., Shimada, H., Tsutsumimoto, K., Lee, S., Doi, T., Nakakubo, S., Hotta, R., & Suzuki, T. (2015). Social Frailty in Community-Dwelling Older Adults as a Risk Factor for Disability. J Am Med Dir Assoc , 16 (11), 1003.e1007-1011. https://doi.org/10.1016/j.jamda.2015.08.023 Segev-Jacubovski, O., & Shapiro, E. (2022). Role of Participation in Activities and Perceived Accessibility on Quality of Life among Nondisabled Older Adults and Those with Disabilities in Israel during COVID-19. Int J Environ Res Public Health , 19 (10). https://doi.org/10.3390/ijerph19105878 Teo, N., Gao, Q., Nyunt, M. S. Z., Wee, S. L., & Ng, T. P. (2017). Social Frailty and Functional Disability: Findings From the Singapore Longitudinal Ageing Studies. J Am Med Dir Assoc , 18 (7), 637.e613-637.e619. https://doi.org/10.1016/j.jamda.2017.04.015 Tsutsumimoto, K., Doi, T., Makizako, H., Hotta, R., Nakakubo, S., Makino, K., Suzuki, T., & Shimada, H. (2017). Association of Social Frailty With Both Cognitive and Physical Deficits Among Older People. J Am Med Dir Assoc , 18 (7), 603-607. https://doi.org/10.1016/j.jamda.2017.02.004 Willer, B., Rosenthal, M., Kreutzer, J., Gordon, W., & Rempel, R. (1993). Assessment of community integration following rehabilitation for traumatic brain injury. The Journal of Head Trauma Rehabilitation , 8 . https://doi.org/10.1097/00001199-199308020-00009 Yamada, M., & Arai, H. (2018). Social Frailty Predicts Incident Disability and Mortality Among Community-Dwelling Japanese Older Adults. J Am Med Dir Assoc , 19 (12), 1099-1103. https://doi.org/10.1016/j.jamda.2018.09.013 Zhang, X. M., Cao, S., Gao, M., Xiao, S., Xie, X., & Wu, X. (2023). The Prevalence of Social Frailty Among Older Adults: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc , 24 (1), 29-37.e29. https://doi.org/10.1016/j.jamda.2022.10.007 Tables Tables 1 to 2 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 27 Apr, 2026 Reviews received at journal 21 Sep, 2025 Reviews received at journal 21 Sep, 2025 Reviewers agreed at journal 02 Sep, 2025 Reviewers agreed at journal 24 Aug, 2025 Reviewers invited by journal 17 Feb, 2025 Editor assigned by journal 30 Jan, 2025 Submission checks completed at journal 30 Jan, 2025 First submitted to journal 27 Jan, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Partial correlation analysis adjusted the effects of age and sex.\u003c/p\u003e\n\u003cp\u003eCIQ: community integration questionnaire.\u003c/p\u003e\n\u003cp\u003e*All X-axis shows social frailty screening index score\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5915848/v1/8abf556ce6deb7c3b35f6e7b.png"},{"id":75316323,"identity":"4c8258fb-a6e8-4ee6-a224-f5821c1761d0","added_by":"auto","created_at":"2025-02-03 09:39:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":425525,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5915848/v1/d16e6ea9-4812-44a0-bab7-3817ad17941b.pdf"},{"id":75314465,"identity":"84257f4c-7e90-48d5-97be-82f189b1b82d","added_by":"auto","created_at":"2025-02-03 09:31:03","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":107891,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-5915848/v1/adcbdd6444dd9b303decb483.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Concurrent validity of the CIQ for assessing social frailty among community-dwelling older adults","fulltext":[{"header":"Background","content":"\u003cp\u003e Social frailty is a serious concern for aged societies because older adults face several social challenges in terms of family structure, economic status, and social participation. Social frailty has negative impacts on health-related outcomes such as physical and cognitive impairment, disability, and death (Ko \u0026amp; Lee, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Makizako et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Teo et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Tsutsumimoto et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Yamada \u0026amp; Arai, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Therefore, it is necessary to promote social participation among older adults and carry out appropriate assessments for the prevention of and recovery from social frailty.\u003c/p\u003e \u003cp\u003eThere are several different assessment tools for social frailty. A systematic review and meta-analysis of the prevalence of social frailty presents three assessment tools that have been widely used to assess social frailty (Zhang et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). One of these three assessment tools, the social frailty screening index, can simply and quickly assess social frailty by answering four questions. In addition, since the question content is based on the concept of social frailty proposed by Bunt et al., (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), the assessment results are easy to interpret. Therefore, this index is suitable for screening for social frailty. However, it is considered unsuitable for judging effectiveness of the prevention of and recovery from social frailty. This is because the social frailty screening index has a small number of items and contains factors that are difficult to change through intervention, such as family structure and economic conditions.\u003c/p\u003e \u003cp\u003eThe community integration questionnaire (CIQ) is one of the assessment tools used to evaluate the state of social participation. The CIQ was developed by Willer and colleagues to assess the handicap of patients with traumatic brain injury (Willer et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e1993\u003c/span\u003e). Since its development, the CIQ has become one of the most widely used assessment tools to measure social participation among subjects. In recent years, the CIQ has been applied to nondisabled older adults (Segev-Jacubovski \u0026amp; Shapiro, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Furthermore, the CIQ is a 15-item standardized self-report questionnaire on participation in social activities. Therefore, it may be able to capture changes in social activities more sensitively than the social frailty screening index. However, the relationship between social frailty and the CIQ in community-dwelling older adults is unclear.\u003c/p\u003e \u003cp\u003eAssessing the risk of social frailty could be helpful with regard to the early interventions required to enhance social engagement. Thus, the aim of this study was to determine whether or not the CIQ can estimate social frailty status defined by the social frailty screening index in community-dwelling older adults.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and participants\u003c/h2\u003e \u003cp\u003eThis cross-sectional study was conducted on community-dwelling older adults in Tokyo, Japan between March and October 2021. Participants were recruited based on an advertisement released in the local press and posters displayed at the senior center. The inclusion criteria were individuals aged 65 and above, who had the ability to walk independently to participate in the health checkup and cooperate in the study. The exclusion criteria were individuals who received Japanese Long-Term Care Insurance (LTCI) services and those whose survey data were missing. Participants using the LTCI services are excluded because they have an aspect of enjoying social participation. This study was conducted in accordance with the guidelines proposed by the Declaration of Helsinki. The study protocol was reviewed and approved by the Ethics Committee of Juntendo Tokyo Koto Geriatric Medical Center (approval No. G20-0016).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eThe community integration questionnaire\u003c/h3\u003e\n\u003cp\u003eWe investigated social participation using the CIQ (Willer et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e1993\u003c/span\u003e). It is a self-administered questionnaire consisting of 15 items and measures community integration based on 3 domains: home integration (e.g., meal preparation and housework), social integration (e.g., shopping, visiting friends, and leisure activities), and productivity (e.g., full vs part-time work, school, and volunteer activities). Most items are rated on a scale of 0\u0026ndash;2, and the total score is calculated within a range of 0\u0026ndash;29 points: home integration (10 points); social integration (12 points); productivity (7 points). A higher score represents greater independence and community integration. In this study, since we intended to investigate the reemployment situation of the subject after retirement, deleted the answer items for retirement due to age.\u003c/p\u003e\n\u003ch3\u003eSocial frailty assessment\u003c/h3\u003e\n\u003cp\u003eWe used a social frailty screening index proposed by Yamada and Arai (Yamada \u0026amp; Arai, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). This index is based on Bunt\u0026rsquo;s social frailty concept that considers general resources, social resources, social behaviors, and the fulfillment of basic social needs (Bunt et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The question regarding general resources (financial difficulties) is, \u0026ldquo;Are you satisfied with your economic condition?\u0026rdquo; The answer choices include (a) very satisfied, (b) satisfied, (c) unsatisfied, and (d) very unsatisfied. \u0026ldquo;Poor general resources (1 point)\u0026rdquo; was operationally defined when the answer was (d). The question regarding social resources (living alone) is, \u0026ldquo;Do you live alone?.\u0026rdquo; \u0026ldquo;Poor social resources (1 point)\u0026rdquo; was defined as living alone. The question regarding social behavior (lack of social activity) is, \u0026ldquo;Which social activities do you participate in (multiple answers allowed)?.\u0026rdquo; The answer choices included (a) local festivals or events, (b) community activities in the neighborhood, (c) self- management groups, and (d) volunteer activities. \u0026ldquo;Poor social behavior (1 point)\u0026rdquo; was operationally defined as participating in none of these activities. The question regarding the fulfillment of basic social needs (influential contact with neighbors) is, \u0026ldquo;How do you get along with your neighbors?.\u0026rdquo; The answer choices included (a) I have a neighbor who visits each house, (b) I have a neighbor to chat with on the street, (c) I have a neighbor to say hello to, and (d) I do not communicate with neighbors. \u0026ldquo;Poor fulfillment of basic social needs (1 point)\u0026rdquo; was defined when the answer was (c) or (d). We defined a point of 2 or higher as social frailty, 1 as social prefrailty, and 0 as robustness according to a previous study (Yamada \u0026amp; Arai, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eOther variables\u003c/h3\u003e\n\u003cp\u003eWe investigated age, sex, height, weight, body mass index, education history, comorbidities, and number of medications through the questionnaire. Additionally, handgrip strength and comfortable walking speed were evaluated as physical function, and Japanese version of Montreal Cognitive Assessment (MoCA-J) (Fujiwara et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) as cognitive function.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eWe compared all variables among the participants who were living alone and not living alone. The differences between the two groups were analyzed using the student\u0026rsquo;s t-test, Mann-Whitney U-test, and chi-squared test. A partial correlation analysis with adjustment for age and sex was performed to examine the correlation between the social frailty screening index and CIQ. The validity of the CIQ for estimating the social frailty status was evaluated using receiver operating characteristics curves. The cut-off value for the optimal estimation of social frailty was determined using the Youden Index. The data were analyzed using the SPSS software (version 28; IBM SPSS Japan, Tokyo, Japan). P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant for all analyses.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 236 participants who met the inclusion criteria, 42 were excluded as they had a certification for LTCI or missing survey data. A total of 194 participants were enrolled in this study. The characteristics of the participants are shown in Table\u0026nbsp;1. The mean age [standard deviation] was 76.3 [5.5] years, 165 participants (85.1%) were women, and the proportion of participants living alone was 44.8%. Significant differences were observed with respect to the sex, height, social frailty screening index, the CIQ total points, and home integration by the CIQ among the two groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003eThe results of the partial correlation analysis are shown in the Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Family integration (r\u0026thinsp;=\u0026thinsp;0.189, p\u0026thinsp;=\u0026thinsp;0.006) had a low positive correlation with the social frailty score. Social integration (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.209, p\u0026thinsp;=\u0026thinsp;0.004), productivity (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.417, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), the CIQ total score (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.204, p\u0026thinsp;=\u0026thinsp;0.005), and the combination of social integration and productivity (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.403, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) had a low to moderate positive correlation with the social frailty score.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eValidity and cutoff point of the CIQ for the social frailty are shown in the Table\u0026nbsp;2. The cutoff values for estimating social frailty were 6/7 (AUC: 0.560, sensitivity: 80.0%, specificity: 36.9%) for home integration, 6/7 (AUC: 0.633, sensitivity: 74.8%, specificity: 46.2%) for social integration, 2/3 (AUC: 0.709, sensitivity: 78.6%, specificity: 60.4%) for productivity, 18/19 (AUC: 0.629, sensitivity: 49.5%, specificity: 71.4%) for the CIQ total score, and 11/12 (AUC: 0.721, sensitivity: 58.3%, specificity: 78.0%) for the combination of social integration and productivity.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigated the relationship between social frailty and the CIQ in community-dwelling older adults. The CIQ was significantly correlated with the social frailty screening index and showed moderate discrimination accuracy. Our findings suggest that the CIQ is a useful tool associated with social frailty.\u003c/p\u003e \u003cp\u003eIn each CIQ item, social integration and productivity were negatively correlated with social frailty, while home integration was positively correlated. A possible reason for home integration to be positively correlated is that the item of social frailty screening index includes living alone. In general, older adults who lead independent lives need to participate in daily activities at home by themselves. In fact, in this study, older adults living alone had significantly higher home integration than those not living alone. A previous study has shown that older adults living alone have more indoor activities than not living alone (Gagliardi et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). For these reasons, home integration may have been inversely correlated with the other items. Therefore, when determining social frailty using the CIQ, it is recommended to use a combination of social integration and productivity, which does not consider home integration while computing the total score.\u003c/p\u003e \u003cp\u003eThe combination of social integration and productivity had the highest discrimination accuracy among the variables examined in this study. However, it had moderate accuracy (AUC: 0.721). The possible reason may have been influenced by the components of social frailty. Bunt\u0026rsquo;s social frailty concept consists of four elements: general resources, social resources, social behavior, and the fulfillment of basic social needs (Bunt et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The social frailty screening index used in this study includes these four elements. However, the CIQ only considers social behavior among the elements of this concept. Therefore, it is possible that the accuracy of determining social frailty using the CIQ remained moderate. Thus, when determining social frailty using the CIQ, it is necessary to consider resources such as family structure and economic situation.\u003c/p\u003e \u003cp\u003eThe strengths and limitations of this study are as follows. The strength of the present study is that it contributes toward the usefulness of the CIQ. The CIQ has more items than the social frailty screening index; the question content includes many controllable elements, such that it is easy to capture changes in social participation. Therefore, it may be useful not only for screening social frailty, but also for determining the effectiveness of the related interventions. A limitation of this study is that sex was not considered as a variable in the analysis. A previous study has shown that there are differences in social participation depending on an individual\u0026rsquo;s sex (Dahan-Oliel et al., 2008). This study had few male participants and could not be stratified by sex. Therefore, future studies are required to further investigate the different uses of the CIQ.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, the CIQ was associated with social frailty in community-dwelling older adults. Furthermore, the combination of social integration and productivity had moderate discrimination accuracy. These results suggest that the CIQ might act as an assessment tool to estimate the risk of social frailty.\u003c/p\u003e"},{"header":"Statements and Declarations","content":"\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis Work was supported by JSPS KAKENHI Grant Number 22H04413, and Tokyo Physical Therapy Association Grant Number 2021004.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eS.K., M.S., K.K.,and Y.K. carried out the investigation. S.K. wrote the manuscript with support from M.S, K.K.. M.S. and K.K. helped supervise the project.S.K. and M.S. conceived the original idea. Y.K. supervised the project.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors acknowledge Mr Yudai Koiwa and Mr Daisuke Ishiyama for their contributions to the data collection.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBunt, S., Steverink, N., Olthof, J., van der Schans, C. P., \u0026amp; Hobbelen, J. S. M. (2017). Social frailty in older adults: a scoping review. \u003cem\u003eEur J Ageing\u003c/em\u003e,\u003cem\u003e\u0026nbsp;14\u003c/em\u003e(3), 323-334. https://doi.org/10.1007/s10433-017-0414-7\u003c/li\u003e\n \u003cli\u003eDahan-Oliel, N., Gelinas, I., \u0026amp; Mazer, B. (2008). Social Participation in the Elderly: What Does the Literature Tell Us\u0026amp;#63.\u003cem\u003e\u0026nbsp;20\u003c/em\u003e(2), 159-176. https://doi.org/10.1615/CritRevPhysRehabilMed.v20.i2.40\u003c/li\u003e\n \u003cli\u003eFujiwara, Y., Suzuki, H., Yasunaga, M., Sugiyama, M., Ijuin, M., Sakuma, N., Inagaki, H., Iwasa, H., Ura, C., Yatomi, N., Ishii, K., Tokumaru, A. M., Homma, A., Nasreddine, Z., \u0026amp; Shinkai, S. (2010). Brief screening tool for mild cognitive impairment in older Japanese: validation of the Japanese version of the Montreal Cognitive Assessment. \u003cem\u003eGeriatr Gerontol Int\u003c/em\u003e,\u003cem\u003e\u0026nbsp;10\u003c/em\u003e(3), 225-232. https://doi.org/10.1111/j.1447-0594.2010.00585.x\u003c/li\u003e\n \u003cli\u003eGagliardi, C., Spazzafumo, L., Marcellini, F., Mollenkopf, H., Ruoppila, I., Tacken, M., \u0026amp; Sz\u0026eacute;man, Z. (2007). The outdoor mobility and leisure activities of older people in five European countries. \u003cem\u003eAgeing and Society\u003c/em\u003e,\u003cem\u003e\u0026nbsp;27\u003c/em\u003e, 683-700. https://doi.org/10.1017/S0144686X07006198\u003c/li\u003e\n \u003cli\u003eKo, Y., \u0026amp; Lee, K. (2022). Social Frailty and Health-Related Quality of Life in Community-Dwelling Older Adults. \u003cem\u003eInt J Environ Res Public Health\u003c/em\u003e,\u003cem\u003e\u0026nbsp;19\u003c/em\u003e(9). https://doi.org/10.3390/ijerph19095659\u003c/li\u003e\n \u003cli\u003eMakizako, H., Shimada, H., Tsutsumimoto, K., Lee, S., Doi, T., Nakakubo, S., Hotta, R., \u0026amp; Suzuki, T. (2015). Social Frailty in Community-Dwelling Older Adults as a Risk Factor for Disability. \u003cem\u003eJ Am Med Dir Assoc\u003c/em\u003e,\u003cem\u003e\u0026nbsp;16\u003c/em\u003e(11), 1003.e1007-1011. https://doi.org/10.1016/j.jamda.2015.08.023\u003c/li\u003e\n \u003cli\u003eSegev-Jacubovski, O., \u0026amp; Shapiro, E. (2022). Role of Participation in Activities and Perceived Accessibility on Quality of Life among Nondisabled Older Adults and Those with Disabilities in Israel during COVID-19. \u003cem\u003eInt J Environ Res Public Health\u003c/em\u003e,\u003cem\u003e\u0026nbsp;19\u003c/em\u003e(10). https://doi.org/10.3390/ijerph19105878\u003c/li\u003e\n \u003cli\u003eTeo, N., Gao, Q., Nyunt, M. S. Z., Wee, S. L., \u0026amp; Ng, T. P. (2017). Social Frailty and Functional Disability: Findings From the Singapore Longitudinal Ageing Studies. \u003cem\u003eJ Am Med Dir Assoc\u003c/em\u003e,\u003cem\u003e\u0026nbsp;18\u003c/em\u003e(7), 637.e613-637.e619. https://doi.org/10.1016/j.jamda.2017.04.015\u003c/li\u003e\n \u003cli\u003eTsutsumimoto, K., Doi, T., Makizako, H., Hotta, R., Nakakubo, S., Makino, K., Suzuki, T., \u0026amp; Shimada, H. (2017). Association of Social Frailty With Both Cognitive and Physical Deficits Among Older People. \u003cem\u003eJ Am Med Dir Assoc\u003c/em\u003e,\u003cem\u003e\u0026nbsp;18\u003c/em\u003e(7), 603-607. https://doi.org/10.1016/j.jamda.2017.02.004\u003c/li\u003e\n \u003cli\u003eWiller, B., Rosenthal, M., Kreutzer, J., Gordon, W., \u0026amp; Rempel, R. (1993). Assessment of community integration following rehabilitation for traumatic brain injury. \u003cem\u003eThe Journal of Head Trauma Rehabilitation\u003c/em\u003e,\u003cem\u003e\u0026nbsp;8\u003c/em\u003e. https://doi.org/10.1097/00001199-199308020-00009\u003c/li\u003e\n \u003cli\u003eYamada, M., \u0026amp; Arai, H. (2018). Social Frailty Predicts Incident Disability and Mortality Among Community-Dwelling Japanese Older Adults. \u003cem\u003eJ Am Med Dir Assoc\u003c/em\u003e,\u003cem\u003e\u0026nbsp;19\u003c/em\u003e(12), 1099-1103. https://doi.org/10.1016/j.jamda.2018.09.013\u003c/li\u003e\n \u003cli\u003eZhang, X. M., Cao, S., Gao, M., Xiao, S., Xie, X., \u0026amp; Wu, X. (2023). The Prevalence of Social Frailty Among Older Adults: A Systematic Review and Meta-Analysis. \u003cem\u003eJ Am Med Dir Assoc\u003c/em\u003e,\u003cem\u003e\u0026nbsp;24\u003c/em\u003e(1), 29-37.e29. https://doi.org/10.1016/j.jamda.2022.10.007\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 2 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"ageing-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"agin","sideBox":"Learn more about [Ageing International](http://link.springer.com/journal/12126)","snPcode":"12126","submissionUrl":"https://submission.springernature.com/new-submission/12126/3","title":"Ageing International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Community-dwelling older adults, the community integration questionnaire, social frailty, social participation","lastPublishedDoi":"10.21203/rs.3.rs-5915848/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5915848/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground/Purpose:\u003c/strong\u003e The community integration questionnaire (CIQ) is one of the assessment tools used to evaluate the state of social participation. We aimed to determine whether or not the CIQ can estimate social frailty status defined by the social frailty screening index in community-dwelling older adults.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod: \u003c/strong\u003eA cross-sectional study was performed in community-dwelling older adults aged 65 and above. We investigated the CIQ, and social frailty using the social frailty screening index. To assess the relationship between social frailty and the CIQ, we performed a partial correlation analysis and receiver operating characteristics curves.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e One hundred and ninety-four participants were enrolled (mean age [standard deviation] was 76.3 [5.5] years). A partial correlation analysis showed that family integration (\u003cem\u003er\u003c/em\u003e = 0.189) had a low positive correlation with the social frailty score. Social integration (\u003cem\u003er\u003c/em\u003e = −0.209), productivity (\u003cem\u003er\u003c/em\u003e = −0.417), the CIQ total score (\u003cem\u003er\u003c/em\u003e = −0.204), and the combination of social integration and productivity (\u003cem\u003er\u003c/em\u003e= −0.403) had a low to moderate positive correlation with the social frailty score. The cutoff values for estimating social frailty were 6/7 (AUC: 0.560) for home integration, 6/7 (AUC: 0.633) for social integration, 2/3 (AUC: 0.709) for productivity, 18/19 (AUC: 0.629) for the CIQ total score, and 11/12 (AUC: 0.721) for the combination of social integration and productivity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion and implications:\u003c/strong\u003e These results suggest that the CIQ is a useful tool associated with social frailty.\u003c/p\u003e","manuscriptTitle":"Concurrent validity of the CIQ for assessing social frailty among community-dwelling older adults","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-03 09:30:58","doi":"10.21203/rs.3.rs-5915848/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-27T12:45:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-21T06:32:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-21T05:49:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"203955065491893469661592837004375618260","date":"2025-09-02T07:17:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"221707523726274045863359776296731489418","date":"2025-08-24T13:29:53+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-02-17T20:41:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-01-30T08:54:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-01-30T08:52:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"Ageing International","date":"2025-01-28T03:22:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"ageing-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"agin","sideBox":"Learn more about [Ageing International](http://link.springer.com/journal/12126)","snPcode":"12126","submissionUrl":"https://submission.springernature.com/new-submission/12126/3","title":"Ageing International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"8b59fc3c-1251-4814-8d7e-6a456e737eb8","owner":[],"postedDate":"February 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-03T12:38:30+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-03 09:30:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5915848","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5915848","identity":"rs-5915848","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}