Validity and Reliability of the Self-Care Activities Screening Scale (SASS-14) During COVID-19 Lockdown

Ma íneze al. Heal h Qual Li e Ou comes (2021) 19:1
h ps://doi.o g/10.1186/s12955-020-01607-6
RESEARCH
Validi y and eliabili y o  heSel -Ca e
Ac i i ies Sc eening Scale (SASS-14)
du ingCOVID-19 lockdown
Ma ín Ma ínez1,2, Elkin O. Luis1,2* , Edwin Yai Oli e os3, Pablo Fe nández‑Be ocal4, Ainize Sa ionandia5,
Ma a Vidau e a6 and Elena Be mejo‑Ma ins2,6
Abs ac
Backg ound: In a con ex whe e he e is no ea men o he cu en COVID‑19 i us, he combina ion o sel ‑ca e
beha iou s oge he wi h con inemen , a e s a egies o dec ease he isk o con agion and emain heal hy. How‑
e e , he e a e no sel ‑ca e measu es o sc een sel ‑ca e ac i i ies in gene al popula ion and which, could be b ie ly
in a lockdown si ua ion. This esea ch aims o build and alida e a psychome ic ool o sc een sel ‑ca e ac i i ies in
gene al popula ion.
Me hods: Fi s ly, an explo a o y ac o analysis was pe o med in a sample o 226 pa icipan s o disco e he unde ‑
lying ac o ial s uc u e and o educe he numbe o i ems in he o iginal ool in o a signi ican pool o i ems ela ed
o sel ‑ca e. La e a con i ma o y ac o analyses we e pe o med in a new sample o 261 pa icipan s o es o he i
and goodness o ac o solu ions. In e nal alidi y, eliabili y, and con e gen alidi y be ween i s sco e wi h pe cei ed
s ess and psychological well‑being measu es we e examined on his sample.
Resul s: The explo a o y analyses sugges ed a ou ‑ ac o solu ion, co esponding o heal h consciousness, nu i‑
ion and physical ac i i y, sleep, and in a‑pe sonal and in e ‑pe sonal coping skills (14 i ems). Then, he ou ‑ ac o
s uc u e was con i med as he bes model i o sel ‑ca e ac i i ies. The ool demons a ed good eliabili y, p edic i e
alidi y o indi iduals’ pe cep ion o coping wi h COVID‑19 lockdown, and con e gen alidi y wi h well‑being and
pe cei ed s ess.
Conclusions: This sc eening ool could be help ul o add ess u u e e alua ions and in e en ions o p omo e
heal hy beha iou s. Likewise, his ool can be a ge ed o speci ic popula ion sel ‑ca e’s needs du ing a scalable
si ua ion.
Keywo ds: Cons uc alida ion, Sel ‑ca e sc eening, Lockdown, COVID‑19, Explo a o y and con i ma o y ac o
analyses
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Backg ound
Heal h is de ined as “a s a e o comple e physical, social
and men al well-being and no me ely he absence o dis-
ease o in i mi y” [1]. Howe e , i can be also conside ed
om a mo e dynamic pe spec i e as he abili y o adap
and sel -ca e in o de o ace physical, social and emo-
ional challenges [2]. Sel -ca e is conside ed as an impo -
an and aluable p inciple because i emphasizes he
ac i e ole o people in main aining hei own wellbeing.
Nowadays, he e is esu gen in e es in he concep and
p ac ice o sel -ca e as an essen ial componen o heal h
p omo ion o imp o e heal h, wellness and wellbeing o
Open Access
*Co espondence: eoswaldo@una .es
1 School o Educa ion and Psychology, Uni e si y o Na a a, Campus
Uni e si a io, 31009 Pamplona, Na a a, Spain
Full lis o au ho in o ma ion is a ailable a he end o he a icle
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Ma íneze al. Heal h Qual Li e Ou comes (2021) 19:1
indi iduals, and as a s a egy o educe he high cos s o
medical se ices [3, 4].
Psychological impac o COVID‑19 lockdown
The cu en ongoing pandemic co ona i us disease 2019
(COVID-19) has sp ead a ound he wo ld while d i ing
global ac ions. In addi ion o he ea o con ac ing he
i us, his si ua ion has led o signi ican changes o ou
daily li es. In o de o suppo e o s o con ain and slow
down he sp ead o he i us, lockdown o manda o y
qua an ine was globally es ablished. Despi e he need o
his Public Heal h ecommended measu e, ou mo e-
men s a e es ic ed; people a e acing new eali ies o
wo king om home, empo a y unemploymen , home
schooling o child en, and lack o physical con ac wi h
o he amily membe s, iends and colleagues [5]. As
esul , people a e e y likely o de elop a wide ange o
symp oms o psychological s ess and diso de , includ-
ing low mood, insomnia, s ess, anxie y, ange , i i abil-
i y, emo ional exhaus ion, dep ession and pos - auma ic
s ess symp oms. Low mood and i i abili y speci ically
s and ou as being e y common [6]. Howe e , ge ing
in ol ed in sel -ca e ac i i ies as pa o hygienic p ac-
ices can help o manage s ess and p e en di icul-
ies and symp oms o heal h p oblems [7]. This scena io
allows examining he main s a egies ha people a e
using o pe sonal sel -ca e, since con inemen es ic-
ions en ail impo an changes on hei daily habi s and
ou ines. This ac leads us o conside ha a popula ion
b ie sc eening o sel -ca e ac i i ies migh be used as an
impo an s a egy o look o as-ye -un ecognised heal h
isk ac o s, which la e , o mal e alua ion and in e en-
ion s a egies can be add essed o.
Sel ‑ca e concep ual model
Al hough he concep o sel -ca e has been b oadly used
in heal hca e li e a u e, many disciplines ha e p o ided
de ini ions o sel -ca e om speci ic pe spec i es [8–10].
Speci ically, O em’s Sel Ca e Model is he mos well-
known heo y on sel -ca e [11]. This heo y iden i ies wo
componen s: he sel -ca e agency (i.e., he abili y o a pe -
son o engage in sel -ca e) and he sel -ca e beha iou s
(i.e., he ac i i ies pe o med by a pe son o main ain li e
and p omo e well-being). Howe e , a ious de ini ions
o sel -ca e ha e eme ged as a esul o he lack o con-
sensus, and mul iple e ms a e used as synonyms o sel -
ca e, such as, sel -agency, sel -e icacy, sel -managemen ,
sel -moni o ing, and sel -help, so i is no always clea
how he e m is de ined [12].
A ecen sys ema ic e iew and concep analysis con-
duc ed by Ma a ese e al. [10] de ines sel -ca e as a b oad
concep ha encompasses all he o he ela ed concep s
which en ails capaci ies, ac i i ies, and p ocesses di ec ed
owa d main aining heal h, p ese ing li e, and moni o -
ing and managing acu e and ch onic condi ions. People
a e suppo ed in his na u al p ocess by hei sel -ca e
abili ies (sel -ca e agency); which a e p e equisi es o ca e
o one’s sel , and by sel -e icacy; which acili a es he
achie emen o desi ed ou comes. Besides, social suppo
is an impo an pa o sel -ca e and people’s amily and
heal hca e p o essionals a e key agen s o p o ide i [10].
Ne e heless, concep ual models nei he om academic
o lay li e a u e, concep ualize sel -ca e in i s o ali y, no
could explain he link be ween sel -ca e ac i i ies, beha -
iou change and esou ce u ilisa ion in he con ex o he
p e ailing cul u e and he ex e nal en i onmen .
In an a emp o co e his gap, he Sel -Ca e Ma ix
(SCM) p oposed by El-os a e  al. [3] has been p o-
posed as a syn hesis o 32 exis ing concep ual models
and amewo ks o cap u e he o ali y o sel -ca e. This
ma ix o models includes ou ca dinal dimensions o
sel -ca e ha could be add essed and measu ed sepa-
a ely as a mac o, meso o mic o-le el s a egy: (1) Sel -
Ca e Ac i i ies, (2) Sel -Ca e Beha iou s, (3) Sel -Ca e
Con ex , and (4) Sel -Ca e En i onmen . A mic o-le el,
which his s udy is aimed o, sel -ca e is conside ed om
a pe son-cen ed pe spec i e and co e s ac i i ies ela ed
di ec ly o wha indi iduals can do o hemsel es, as well
as he knowledge equi ed o in o m sui able sel -ca e
choices. To add ess his i s dimension, he Se en Pilla s
o Sel -Ca e amewo k de eloped by he In e na ional
Sel -Ca e Founda ion has been conside ed he bes can-
dida e o explo e he sel -ca e ac i i ies dimension [3].
This model in ol es se en pe sonal ac i i ies such as,
knowledge, sel -awa eness and heal h li e acy, psycho-
logical well-being, physical ac i i y, heal hy ea ing, good
hygiene and he a oidance o isks such as, obacco and
excessi e alcohol consump ion and a ional use o p od-
uc s and se ices.
Mo eo e , sel -ca e ac i i ies a e di ec ly ela ed o he
heal h consciousness concep , which e e s o sel -awa e-
ness abou one’s heal h, and he willingness o engage
in heal h and wellness p omo ing beha iou s [13–15].
In his way, sel -ca e ac i i ies a e a p edic o o well-
being, which may be de e minan o wellness pa icipa-
ion [15]. I leads heal h conscious indi iduals o ac i ely
seek in o ma ion abou how o imp o e hei heal h, and
adhe e o heal h beha iou s acco dingly [16–18]. Hence,
indi iduals wi h high heal h consciousness ha e posi i e
a i udes abou sel -ca e ac i i ies and ha e heal hie li e-
s yles han indi iduals wi h low heal h consciousness [13,
19, 20].
Sel ‑ca e measu es
Se e al ins umen s ha e been de eloped o assess sel -
ca e in many di e en popula ions, and o a ious heal h
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Ma íneze al. Heal h Qual Li e Ou comes (2021) 19:1
condi ions, such as pa ien s wi h ype 2 diabe es, [21],
people wi h hype ension [22], child en [23], o gene al
adul popula ion [24].
A ecen sys ema ic e iew was speci ically conduc ed
on he ins umen s designed o assess sel -ca e in heal h
p omo ion and main enance in he adul popula ion [25]
in which nine ins umen s we e iden i ied: App aisal o
Sel -ca e Agency Scale (ASA-A) [26, 27], Denyes Sel -
Ca e P ac ice Ins umen (DSCPI-90) [28], Denyes
Sel -Ca e Agency Ins umen (DSCAI) [29], Exe cise
o Sel -Ca e Agency (ESCA) [30], Lo ensen’s Sel -ca e
Capabili y Scale (LSCS) [31], Pe cei ed Sel -Ca e Agency
Ques ionnai e (PSCAQ) [32], Sel -ca e Abili y Scale o
he Elde ly (SASE) [33], Sel -as-Ca e In en o y (SCI)
[34], Sel -Ca e o Home-Dwelling Elde ly (SCHDE) [35].
In he abo e-men ioned e ision mos o he selec ed
s udies p esen ed me hodological limi a ions and hei
quali y was a ed as “nega i e o inde e mina e” [25].
Despi e he numbe o de eloped ins umen s ela ed
o he sel -ca e concep , mos o hem a e mainly based
on he sel -ca e agency a ibu e, which is de ined as
he capabili ies o an indi idual o ecognize his o he
own needs and o assess pe sonal and en i onmen al
esou ces [36]. Howe e , o ou knowledge, none has
been iden i ied o sc een, assess o e alua e he speci ic
dimension o sel -ca e ac i i ies conside ing heal h con-
sciousness as a key elemen o sel -ca e.
The e o e, he e is a need o de elop a b ie sc eening
ool wi h app op ia e psychome ic p ope ies ( eliabili y
and alidi y), o ake measu es o e alua e he sel -ca e
ac i i ies, including heal h consciousness dimension and
ha can be applied in simila si ua ions when heal h and
well-being is comp omised. In his way, he ocus o his
s udy is o build a alid and eliable sho ool o sc een-
ing sel -ca e ac i i ies in Spanish-speake popula ion
du ing COVID-19 lockdown.
The speci ic objec i es co e ed in his s udy we e: (1) o
design and explo e he ac o ial s uc u e o an o iginal
se o i ems o sc een sel -ca e ac i i ies in a COVID-19
con ined sample, and (2) o con i m he ac o s uc u e
o he ool in an independen COVID-19 con ined sam-
ple. In addi ion, we examine he eliabili y o he p o-
posed scale and i s con e gen alidi y wi h well-being
and s ess measu es.
Me hods
Pa icipan s
In his s udy, wo samples o gene al popula ion om
Colombia we e ec ui ed h ough an online su ey
sp ead h ough social media. Pa icipan s we e an-
domized o selec a minimum o 30 people wi hin he
ollowing i e age anges: 18–28, 29–39, 40–49, 50–59,
and olde han 60. As esul , Sample 1 (i.e., explo a-
o y sample) was composed 226 pa icipan s, whe eas
sample 2 (i.e., con i ma o y sample) consis ed o 261
pa icipan s. Indi iduals’ in o ma ion o bo h samples
was collec ed a he same ime, speci ically, du ing he
beginning o he COVID-19 lockdown (i.e., om 31 h
Ma ch o 14 h Ap il o 2020). E hical app o al was
ob ained by he Resea ch E hics Commi ee o he Uni-
e si y o Na a a (P ojec ID: 2020.058) and by he
Colombian s anda ds o esea ch in psychology.
P ocedu e
Fi s , socio-demog aphic da a and i ems ela ed o
COVID-19 lockdown we e included (i.e., age, sex, ci y,
coun y, socio-economic s a us, le el o s udies com-
ple ed, p o essional g oup, being in cha ge o olde and
child en), employmen si ua ion p e ious and subse-
quen o COVID-19 lockdown, in o ma ion ela ed o
COVID-19 lockdown (i.e., numbe o days in con ine-
men , numbe o people li ing wi h and heal h s a us
(i.e., his o ical psychological and physical illnesses).
In o de o c ea e he ini ial pool o i ems ela ed
o sel -ca e, au ho s e iewed he li e a u e o exis -
ing scales a emp ing o assess sel -ca e. Based on he
Se en Pilla s o Sel -Ca e amewo k [3], i s sel -ca e
ac i i ies dimensions we e ope a ionalized. Ne e he-
less, some o he amewo k’s ac i i ies we e me ged in
one unique dimension as well as, o he s impo an sel -
ca e ac i i ies we e newly included o comple e his
model. A e his concep ual p ocess, wo au ho s: EB
(nu se specialized in he heo e ical ield o sel -ca e,
and EL (psychologis specialis in he ope a ionaliza-
ion o psychological cons uc s) de eloped 17 i ems
each, esul ing in 34 i ems co e ing hese ac i i ies. As
esul , 9 sel -ca e ac i i ies dimensions: 1. Heal h Con-
sciousness (6 i ems); 2. In ape sonal Skills (2 i ems);
3. Social Suppo (3 i ems); 4. Physical Ac i i y and
Heal hy Ea ing (4 i ems); 5. Sleep quali y (2 i ems); 6.
Spa e Time ac i i ies (3 i ems); 7. Hygiene (2 i ems); 8.
In o ma ion A i ude Consump ion (4 i ems), and 9.
Subs ance Abuse (8 i ems). I is wo hy o men ion ha
i ems om he heal h consciousness dimension we e
ansla ed and adap ed om he Heal h Consciousness
Scale (HCS) [15] a ailable in English language.
F om he ini ial 34 i ems, we emo ed hose wi h
bina y esponses, las ing a o al o 24 i ems which
we e o ganized by dimensions and coded in Like
scale anging om 1 = Ne e o 6 = Always depend-
ing on each sel -ca e ac i i y equency. The ins u-
men was hen uploaded on an online pla o m o be
sel -adminis a ed.
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Ma íneze al. Heal h Qual Li e Ou comes (2021) 19:1
S a is ical analyses
Cons uc alidi y
Desc ip i e s a is ics and eliabili y and alidi y analy-
ses we e conduc ed using S a a 15. In o de o achie e a
psychome ically sound measu e ha holds unde alida-
ion, explo a o y ac o analysis (EFA) was used as a i s
s ep o e sample 1, whe eas con i ma o y ac o analyses
(CFAs) we e applied la e in an independen sample (i.e.,
sample 2). The i s goal was o educe he se o 24 i ems
o hose ha bes exempli ied he p oposed dimensions
wi hou loading oo high on one o mo e o he o he
dimensions. EFA can be used o de e mine whe he he
hypo hesized ac o s uc u e is ac ually e lec ed in he
collec ed da a, and allows educing he numbe o i ems
o keep hose wi h he s onges indica ions o con o m-
ing o he p oposed unde lying s uc u e [37]. In con as
o he EFA, CFA p o ides a mo e es ic i e es o he
hypo hesized ac o s uc u e by pe mi ing imposed
es ic ions on ela ionships be ween obse ed a iables
and ac o s [38].
Explo a o y ac o analysis
The in e nal consis ency o he ini ial 24 i ems was es i-
ma ed h ough he C onbach’s alpha coe icien meas-
u ed o e sample 1. Fi s , we checked he condi ions o
a s able ac o s uc u e in he da a h ough he Kaise –
Meye –Olkin measu e and we checked o o e all sig-
ni icance in he co ela ions wi hin he i ems’ co ela ion
ma ix by means o a Ba le ’s es o sphe ici y. An EFA
wi h p incipal componen analysis (i.e., o allow o ind-
ing linea combina ions o he a iables wi h he g ea es
a iance) was employed o ex ac he la en dimensions
o he o iginal ques ionnai e, whe e an o hogonal Va i-
max o a ion (i.e., o minimize he numbe o a iables
wi h high loading on each ac o , and o simpli y he
in e p e a ion o he ac o solu ion) was selec ed. We
e ained hose i ems wi h ac o loadings g ea e han
0.5 and wi h a minimum di e ence in ac o loading on
he emaining ac o s o 0.2 [39], i ems ha would com-
pose he inal scale. De e mining he numbe o ac o s
o he inal solu ion in he explo a o y sample was guided
by pa allel analysis wi h 500 andomly co ela ed ma i-
ces [40]. Wi h pa allel analysis a andom gene a ed se
o Eigen alues is compa ed o he empi ically de i ed
Eigen alues.
Con i ma o y ac o analyses
We used CFAs so ha he hypo hesized ac o solu ion
ob ained du ing EFA in sample 1 can be es ed o i s i
o he obse ed co a iance s uc u e in an independen
sample. Acco ding o ecommenda ions o scale de el-
opmen [41], CFAs wi hin he s uc u al equa ion model-
ling amewo k we e applied o es he unde lying ac o
s uc u e o he solu ion ob ained du ing EFA in sample
2. All es s we e conduc ed using maximum-likelihood
es ima ion wi h a logi link unc ion o accoun o he
o dinal na u e o he esponse scale. CFA models wi h
one and n-co ela ed ac o s we e conside ed since a uni-
dimensional solu ion was ini ially hypo hesized, bu we
also conside ed he n- ac o solu ion esul ed in he EFA.
In he i s CFA, we analysed he i o a uni- ac o ial
model wi h he solu ion de e mined by he EFA. In he
second CFA, we analysed he i o a co ela ed n- ac o
model wi h he solu ion de e mined by he EFA. To indi-
ca e goodness o i o he model, we used he chi-squa e
measu e, Compa a i e Fi Index (CFI), Tuke Lewis
Index (TLI), S anda dized Roo Mean Squa ed Resid-
ual (SRMR) i index, Bayesian in o ma ion c i e ion
(BIC), Akaike’s in o ma ion c i e ion (AIC), and Roo
Mean Squa e E o o App oxima ion (RMSEA). Good
i is indica ed by alues unde 0.06 o RMSEA, alues
abo e 0.90 o CFI, and alues close o 0.95 o TLI [42].
The in e nal consis ency o he scale and i s subdimen-
sions was measu ed by means o he C onbach alpha’s
coe icien .
Con e gen alidi y
In addi ion o sel -ca e, he Spanish adap a ion o he
Ry ’s Psychological Well-Being Scale-29 (PWBS-29) [43]
and he Pe cei ed S ess Scale (PSS-10) [44] we e admin-
is e ed in o de o e alua e o con e gen alidi y in he
sel -ca e’s ool. The in e nal consis ency o he PWBS-29
and he PSS-10 was e alua ed by means o he C onbach
alpha’s coe icien .
The PWBS-29 is composed o 29 i ems scaled om
1 o 6 and s uc u ed in six dimensions, namely: Sel -
accep ance (SA), Posi i e ela ionships wi h o he s
(PRO), Au onomy (ATM), En i onmen al mas e y (EM),
Pu pose in li e (PL), and Pe sonal g ow h (PG), wi h a
minimum sco e o 29 and a maximum sco e o 174. The
Spanish e sion o he PWBS-29 has adequa e psycho-
me ic p ope ies [43] wi h accep able o high in e nal
consis ency in i s subscales ( om 0.68 o 0.83).
The PSS-10 is a sho ques ionnai e composed o 10
i ems ( om 0 = Ne e o 4 = Ve y o en) ha e alua es
he pe cei ed s ess du ing he las mon h. The Spanish
e sion o he PSS-10 has adequa e psychome ic p ope -
ies wi h high in e nal consis ency (α = 0.81), and accep -
able es – e es eliabili y ( = 0.73) [45].
Conside ing he ela ionship be ween sel -ca e and
well-being [46] and wi h pe cei ed s ess [47], we
expec ed signi ican posi i e and nega i e co ela ions
be ween hei sco es, espec i ely. A alue o p < 0.05 was
selec ed as a signi icance h eshold, whe eas Bon e oni
co ec ion me hod was applied o co ec o mul iple
compa isons.
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Ma íneze al. Heal h Qual Li e Ou comes (2021) 19:1
Resul s
Pa icipan s
Pa icipan s o sample 1 (i.e., explo a o y sample) anged
om 19 o 80 yea s old (M = 38.31, SD = 12.40), and
consis ed mainly o emales (54.9%, 124/226). In ela-
ion wi h he educa ion le el, he majo i y o he pa ici-
pan s (73.4%, 95/166) had inished uni e si y educa ion,
whe eas he 13.7% had inished high school (12/31),
11.9% had inished echnical s udies (16/27), and 1%
had inished elemen a y educa ion (1/2). The economic
mon hly income o he sample was as ollows: he 17.5%
had no income (27/40), he 11.9% ea ned less han a
minimum wage mon hly (mwm = 300 USD) (16/27),
he 16.4% ea ned 2 mwm (18/37), he 18.6% ea ned 3
mwm (22/42), he 12.4% ea ned 4 mwm (12/28), he 15%
ea ned mo e han 5 mwm (16/34), and he 18.8% p e-
e ed no o answe (13/18).
Pa icipan s o sample 2 (i.e., con i ma o y sample)
anged om 19 o 90yea s old (M = 44.36, SD = 16.11),
and consis ed o mainly emale (61.3%, 160/261). In ela-
ion wi h he educa ion le el, he majo i y o he pa -
icipan s had inished uni e si y educa ion (73.95%,
121/193), whe eas he 11.1% had inished high school
(13/29), 14.2% had inished echnical s udies (25/37),
and 1% had inished elemen a y educa ion (1/2). The
economic mon hly income o he sample was as ol-
lows: he 13.4% had no income (25/35), he 9.6% ea ned
less han 1 mwm = 300 USD (18/25), he 13.4% ea ned
2 mwm (24/35), he 21.5% ea ned 3 mwm (36/56), he
9.6% ea ned 4 mwm (15/25), he 21.5% ea ned mo e han
5 mwm (23/56), and he 11.1% p e e ed no o answe
(19/29).
Explo a o y ac o analysis
The in e nal consis ency o he 24 i ems was α = 0.807.
The Kaise –Meye –Olkin measu e o sampling ade-
quacy exhibi ed high s eng h in he ela ionships among
i ems (KMO = 0.821). The Ba le ’s es o sphe ici y
demons a ed signi icance in all he co ela ions wi hin
he i ems’ co ela ion ma ix (χ2 = 1718.56, p < 0.001).
Thus, bo h es s indica ed ha he p esen da a we e
app op ia e o use on a ac o analy ic model.
The EFA was pe o med wi h all 24 i ems o e he
explo a o y sample 1. Du ing ac o ex ac ion, eigh
ac o s we e ound wi h he ollowing Eigen alues: 3.64,
2.43, 2.29, 2.22, 1.55, 1.23, 1.21, and 1.15. Ne e heless,
pa allel analysis indica ed ha only ou ac o s should be
ex ac ed. The e o e, we may conclude ha ou ac o s
p obably a e he mos accu a e numbe o be ex ac ed
om hese da a. The ou - ac o solu ion ob ained in
he EFA explained 43.3% o he o al a iance in he da a
ma ix wi h 14 i ems loading on his solu ion, whe eas
he analysis disca ded he o he 10 i ems. Thus, he i ems
ha bes i ed he ou ac o s men ioned abo e we e
selec ed o compose he Sel -Ca e Ac i i ies Sc een-
ing Scale (SASS-14). These i ems and hei ac o load-
ings and unique a iances a e o a ion a e indica ed in
Table1.
The alues o he ac o s’ a iances a e o a ion we e
3.19 (33.9%) o Fac o 1, 2.10 (22.3%) o Fac o 2, 1.57
(16.7%) o Fac o 3, and 1.16 (12.3%) o Fac o 4, ha
explained he 85% o he o al a iance in he model,
wi h a o al o 14 i ems. Based on hese esul s, h ee
dimensions kep he ini ial con en and label, (1) Heal h
consciousness (HC, 5 i ems), (2) Nu i ion and Physical
Ac i i y (NPA, 3 i ems), (3) Sleep quali y (SLP, 2 i ems),
whe eas he ou h dimension was composed o 4 i ems
om he o iginal Social Suppo , In ape sonal Skills and
Spa e Time Ac i i ies dimensions, and was labelled as (4)
In e pe sonal and In ape sonal coping s a egies (IICS).
I should be no ed ha a compa ison o he o iginal
o hogonal Va imax o a ed solu ion wi h he oblique
Oblimin solu ion showed ha bo h esul s we e com-
pa able, lending suppo o his i em selec ion. The eli-
abili y o he SASS-14 was α = 0.831, demons a ing good
in e nal consis ency in sample 1. The 14 i ems o he p o-
posed SASS-14 we e subjec ed o CFAs on an independ-
en sample.
Con i ma o y ac o analyses
Fi s , a one- ac o model whe e all i ems loaded on one
dimension (e.g., sel -ca e) was es ed o e sample 2. The
chi-squa e was 566.17, d = 77, p < 0.001, CFI = 0.579,
TLI = 0.503, SRMR = 0.121, BIC = 12,336.976,
AIC = 12,187.266, RMSEA = 0.156. Nex , he co ela ed
ou - ac o model de i ed om he explo a o y analysis
was es ed. The chi-squa e was 171.674, d = 71, p < 0.001,
CFI = 0.913, TLI = 0.89, SRMR = 0.056, BIC = 11,976.868,
AIC = 11,805.771, RMSEA = 0.074. A compa ison
be ween he goodness and i ing o bo h models indi-
ca ed ha he co ela ed ou - ac o model ep esen ed a
be e app oxima ion in e ms o i and goodness. The e-
o e, we selec ed his model as a alid ep esen a ion
o he sel -ca e cons uc (Fig.1). The mean sub-scales
sco es o he SASS-14 di e en ia ed by age a e de ailed
in Table2, oge he wi h he size, he s anda d e o , and
he 95% con idence in e al.
Rega ding eliabili y, he C onbach’s alpha coe icien
o he SASS-14 was 0.801 in he con i ma o y sample,
whe eas he in e nal consis ency o i s dimensions we e
αHA = 0.85, αDPA = 0.61, αSLP = 0.86, and αIICS = 0.57.
Thus, he in e nal consis ency o he SASS-14 was good
wi h accep able o high (0.57–0.86) eliabili y in i s
subscales.

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Table 1 Ro a ed solu ion gene a ed on heEFA inS udy 1 (n = 226)
I em numbe I em con en
(Spanish) I em con en
( ansla ed
oEnglish)
Fac o 1 Fac o 2 Fac o 3 Fac o 4 Uniqueness
SASS1Es oy ale a de los
cambios en mi
salud
I am ale o changes
in my heal h
0.77 0.30
SASS2Po lo gene al, soy
muy conscien e de
mi salud
I am usually awa e o
my heal h
0.73 0.33
SASS3Re lexiono mucho
sob e mi salud
I e lec abou my
heal h a lo
0.86 0.23
SASS4Es oy a en a/o a mis
sen imien os con
espec o a mi salud
I know my inne
eelings abou my
heal h
0.80 0.27
SASS5Es oy cons an e-
men e exami-
nando mi salud
I am cons an ly
examining my
heal h
0.76 0.30
SASS6Realizo ac i idad
ísica (algún
depo e, yoga o
baile) du an e al
menos 30 minu os
dia ios
I do physical ac i i y
(some spo , yoga
o dance) o a
leas 30 min a day
0.75 0.25
SASS7Como es po ciones
de u a y dos de
e du a dia ia-
men e
I ea h ee se ings
o ui and wo o
ege ables daily
0.50 0.36
SASS8Conside o que
es oy comiendo
mejo que an es
(menos azúca , sal,
ape i i os i os o
comida p ecoci-
nada)
I hink I am ea ing
be e han I used
o (less suga , sal ,
ied snacks o p e-
cooked ood)
0.51 0.46
SASS9Es oy bebiendo una
media de 8 asos
de agua dia ios
I’m d inking an a e -
age o 8 glasses o
wa e a day
0.79 0.34
SASS10 Due mo en e 7–8
ho as dia ias
I sleep 7–8 h a day 0.86 0.23
SASS11 Conside o que mi
descanso es de
calidad
I hink ha my es is
o quali y
0.83 0.26
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Table 1 (con inued)
I em numbe I em con en
(Spanish) I em con en
( ansla ed
oEnglish)
Fac o 1 Fac o 2 Fac o 3 Fac o 4 Uniqueness
SASS12 Es oy ap endiendo a
hace cosas nue as
como: oca un
ins umen o,
depo e, p ac ica
un idioma, cocina ,
pin a , nue as
apps, ideojuegos,
e c.…
I am lea ning o
do new hings
like: playing an
ins umen , spo s,
p ac icing a new
language, cooking,
pain ing, new
apps, ideo games,
e c. …
0.51 0.43
SASS13 Pa icipo ac i a-
men e en las
inicia i as de mi
comunidad (p.ej:
aplaudi , can a ,
pone música,
o ece mi apoyo
en lo que pudie a
ayuda , e c.)
I ac i ely pa icipa e
in he ini ia i es
o my communi y
(eg: clapping,
singing, playing
music, o e ing my
suppo in wha I
could help, e c.)
0.70 0.31
SASS14 Es oy encon ando
momen os
pa a es a más
conec ada/o
conmigo misma/o
(obse o, esc ibo
o e lexiono sob e
mis pensamien-
os, emociones o
conduc as)
I am inding
momen s o be
mo e connec ed o
mysel (I obse e,
w i e o e lec on
my hough s, emo-
ions o beha io s)
0.71 0.34
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Con e gen alidi y
All he sub-scales o he SASS-14 (including he o al
sco e) we e ound o be signi ican ly and posi i ely co e-
la ed wi hin hem and also wi h almos all he sub-scales
o he PWBS-29-excep wi h posi i e ela ionships and
au onomy- and wi h he o al sco es o he PWBS-29
and PSS-10, suppo ing con e gen alidi y be ween sel -
ca e and well-being and pe cei ed s ess measu es (see
Table3).
Wi hin he SASS-14 sub-scales, he highes co ela ion
was ound be ween NPA and IICS ( = 0.46, p < 0.001)
and he lowes co ela ion was ound be ween HC and
NPA ( = 0.23, p = 0.001) and also be ween HC and IICS
( = 0.23, p = 0.001). The highes co ela ions be ween
he SASS-14 and he PWBS-29 we e ound be ween
SLP and SA ( = 0.42, p < 0.001) and also be ween SLP
and PL ( = 0.42, p < 0.001). The co ela ion coe icien
be ween he o al sco es o he SASS-14 wi h he PWBS-
29 was 0.43 (p < 0.001) and wi h he PSS-10 was − 0.29
(p < 0.001). The e o e, his analysis con i med con e gen
alidi y be ween sel -ca e and well-being sco es, and also
be ween sel -ca e and s ess on his sample. Finally, he
C onbach’s alpha coe icien s o he PWBS-29 and PSS-
10 scales we e 0.90 and 0.85, espec i ely.
Discussion
In his s udy, we de elop and alida e a b ie ool o
sc eening sel -ca e in gene al popula ion du ing he
COVID-19 lockdown: he SASS-14. Fi s , an EFA sug-
ges ed ha he ins umen has a co ela ed ou - ac o
s uc u e, in e p e ed as heal h consciousness, nu i ion
and physical ac i i y, sleep, and in e pe sonal and in ap-
e sonal coping s a egies. This ac o s uc u e was con-
i med by he CFA pe o med on an independen sample.
Las ly, he ool demons a ed o be a eliable measu e
wi h good in e nal consis ency and con e gen alidi y
wi h psychological well-being and wi h pe cei ed s ess
measu es.
Despi e sel -ca e concep ual model highligh s he
impo ance o isk a oidance (subs ance use o a i ude
Fig. 1 Diag am o he co ela ed ou ‑ ac o model wi h s anda dized es ima es alida ed in S udy 2
Page 9 o 12
Ma íneze al. Heal h Qual Li e Ou comes (2021) 19:1
and in o ma ion consump ion), hygiene ou ines (le el
o sunligh and di e en ial spaces o wo k and es ),
o social suppo (people o alk wi h o communi y
social esou ces), i ems ela ed o hese dimensions
we e no ep esen ed by any s able ac o in he EFA.
This may be explained by he ac ha some o hese
i ems can espond o ac i i ies ha du ing he lock-
down a e no p esen ing any cohe en pa e n in peo-
ple’s answe s, as social in e ac ions ha unde line some
o hese beha iou s a e e y in luenced by his si ua ion
(e.g. social ac i i ies, spa e ime o subs ance abuse).
Mo eo e , i may also explain why some o hese i ems
ended included in he new dimension in e pe sonal
and in ape sonal copying s a egies, since i included
ac i i ies ela ed o in ospec ion, social in e ac ion
o communi y pa icipa ion ha a e being o help o
people o o e come a s ess ul si ua ion (e.g. i ems
12, 13 and 14). The e o e, while he sel -ca e’s dimen-
sions disca ded by he EFA could play a ele an ole
in sel -ca e, hey could be mo e linked o con ex ual
ac o s (i.e., ex e nal esou ces a home, communi y o
heal hca e se ings) and sel -ca e beha iou s (i.e., p in-
ciples and ac ions ha suppo and mo i a e indi idu-
als o achie e he sus ained adop ion o heal h-seeking
beha iou s and li es yles choices); s a egies which may
be inhibi ed du ing a con inemen si ua ion. The e o e,
hese dimensions could i be e wi h he second and
hi d dimension o he Sel -Ca e Ma ix [3] and hence,
e alua ed sepa a ely.
The e a e di e en ins umen s ha ha e been de el-
oped o e alua e sel -ca e [25]. Au ho s such as [16],18
ha e epo ed heal h consciousness as a undamen al
aspec in he ac i e sea ch o in o ma ion ela ed o sel -
ca e imp o emen and ac ion. The e o e, he inclusion o
his ac o can be conside ed as a ca alys o all sel -ca e
ac i i ies. Howe e , p e ious sel -ca e ins umen s do
no conside his ac o wi hin sel -ca e cons uc , which
can be conside ed as s eng h o his s udy. Addi ionally,
none sel -ca e ins umen s we e iden i ied o sc een sel -
ca e ac i i ies ha can be applied du ing a s ess ul si u-
a ion as a con inemen . These esul s sugges ha , du ing
a lockdown, people could educe hei sel -ca e ou ines
in o de o sa is y hei e y basic needs. Which could
imply ha heal h p e en ion s a egies in his kind o
si ua ions should p ima ily sc een hese basic aspec s o
sel -ca e: physical, nu i ional and sleep, emo ional and
social coping.
As expec ed, a signi ican posi i e co ela ion was
ound be ween he o al sco e o he SASS-14 and ha
o he PWBS-29, indica ing ha he highe sel -ca e’s
sco es, he highe le els o well-being. On he o he hand,
a signi ican nega i e co ela ion was ound be ween he
o al sco e o he SASS-14 and ha o he PSS-10, indi-
ca ing ha , he highe sco es in sel -ca e, he lowe le els
in pe cei ed s ess. Bo h esul s a e in line wi h p e ious
s udies. Rega ding, sel -ca e and well-being, i has been
ound ha pe o ming sel -ca e ac i i ies is associa ed
o he heal h consciousness concep . Thus, people who
engage wi h sel -ca e ac i i ies ha e he willing o p o-
mo e heal h and wellness [13, 14]. In such a way, sel -ca e
is p edic i e o well-being, wha may be de e minan o
wellness pa icipa ion [15]. Rega ding s ess, he exis -
en li e a u e has shown an in e se ela ionship be ween
sel -ca e and s ess. A esea ch conduc ed on g adua e
s uden s demons a ed ha daily habi s ela ed o sleep
and exe cise we e ela ed o a lowe s ess pe cep ion
[48]. Likewise, sel -ca e p ac ices ha e been ound o be
Table 2 Age- ela ed a ing ancho s o  he SASS-14 o al
andsub-scales sco es in he alida ion sample (n = 261)
HC heal h consciousness, NPA nu i ion and physical ac i i y, SLP sleep, IICS in a-
pe sonal and in e -pe sonal coping skills, SASS Sel -ca e Ac i i ies Sc eening
Scale
Size Mean SE 95% CI
18–28 yea s
HC 56 23.46 0.71 22.03 24.90
NPA 56 13.43 0.59 12.25 14.60
SLP 56 8.75 0.34 8.06 9.44
IICS 56 11.34 0.50 10.33 12.35
SASS 56 56.98 1.62 53.74 60.22
29–39 yea s
HC 55 25.26 0.56 24.24 26.49
NPA 55 14.33 0.57 13.18 15.47
SLP 55 8.80 0.40 7.99 9.61
IICS 55 10.51 0.50 9.52 10.5
SASS 55 59 1.32 56.28 61.72
40–49 yea s
HC 46 25.35 0.61 24.12 26.57
NPA 46 14.80 0.64 13.52 16.08
SLP 46 9.15 0.37 8.40 9.90
IICS 46 10.96 0.59 9.78 12.13
SASS 46 60.26 1.62 56.99 63.43
50–59 yea s
HC 39 26.05 0.79 24.45 27.65
NPA 39 15.62 0.70 14.20 17.03
SLP 39 9.44 0.40 8.62 10.25
IICS 39 11.33 0.57 10.18 12.49
SASS 39 62.44 1.65 59.10 65.77
> 60 yea s
HC 65 25.17 0.52 24.14 26.20
NPA 65 15.30 0.51 14.29 16.33
SLP 65 9.92 0.28 9.37 10.47
IICS 65 11.46 0.43 9.60 11.32
SASS 65 60.86 1.14 58.58 63.14