Health Activation Scale for Children

1. Abstract

The Health Activation Scale for Children (HAS-C) is a specialized psychometric assessment instrument developed to measure the degree of health activation among pediatric populations, specifically targeting primary school-aged children between 8 and 12 years of age. Traditionally conceptualized and operationalized within adult cohorts managing chronic physical illnesses—most prominently via the Patient Activation Measure (PAM)—health activation encompasses an individual’s knowledge, skills, behavioral confidence, and intrinsic readiness to manage their personal health and health care. Recognizing that foundational health beliefs, behavioral trajectories, and lifestyle habits crystallize during middle childhood, the HAS-C recalibrates this adult-centric construct into a developmentally calibrated, health-promotive framework suitable for pediatric health psychology and school-based health initiatives.

The instrument consists of a 12-item self-report questionnaire configured across three distinct, interrelated psychological dimensions: Health Beliefs (4 items), Behavioural Confidence (4 items), and Intention for Action (4 items). Responses are captured using an authentic 4-point Likert scale ranging from 1 (“Strongly Disagree”) to 4 (“Strongly Agree”). Extensive empirical validation conducted with primary school children in Singapore demonstrated robust psychometric integrity. The total scale exhibited strong internal consistency (Cronbach’s alpha = .844), with subscale coefficients demonstrating acceptable reliability across domains (.732 for Health Beliefs, .698 for Behavioural Confidence, and .753 for Intention for Action).

Structural validity evaluated via Confirmatory Factor Analysis (CFA) established an excellent data-to-model fit (Comparative Fit Index [CFI] = .968; Tucker-Lewis Index [TLI] = .954; Root Mean Square Error of Approximation [RMSEA] = .044; $\chi^2/df = 1.583$). By shifting the clinical paradigm from reactive chronic disease self-management to proactive pediatric health promotion and micro-decision autonomy, the HAS-C serves as a vital intermediate outcome measure. It enables researchers, educators, and pediatricians to evaluate the efficacy of behavioral interventions and quantify emerging health autonomy in school-aged youth.

2. Keywords

health activation, children, psychometrics, health promotion, scale development, pediatric health, self-efficacy, Health Activation Scale for Children, behavioral readiness, primary education, childhood autonomy, health beliefs

3. Authors

The Health Activation Scale for Children was conceptualized, developed, and psychometrically validated by a multidisciplinary team of health services researchers and clinical scientists based in Singapore:

• Lixia Ge (Corresponding Author) — Health Services & Outcomes Research, National Healthcare Group, Singapore. Email: [email protected]
• Joseph Molina — Health Services & Outcomes Research, National Healthcare Group, Singapore.
• Ramakrishnan Karthigayan — Health Services & Outcomes Research, National Healthcare Group, Singapore.
• Hui Ting Foo — Health Services & Outcomes Research, National Healthcare Group, Singapore.
• Marcus Tang — Health Services & Outcomes Research, National Healthcare Group, Singapore.
• Rochelle Chua — Health Services & Outcomes Research, National Healthcare Group, Singapore.
• Chin Fung Ong — Health Services & Outcomes Research, National Healthcare Group, Singapore.

4. Purpose

The primary clinical, educational, and public health objective of the Health Activation Scale for Children (HAS-C) is to systematically evaluate a child’s internal motivation, self-regulatory competence, and behavioral capacity to participate proactively in their personal health. Historically, the measurement of health activation has remained inextricably bound to adult clinical literature. Seminal assessment batteries such as the Patient Activation Measure (PAM) evaluate an adult’s perceived agency, understanding of diagnostic parameters, capacity to navigate sophisticated healthcare delivery systems, and direct collaboration with multidisciplinary clinical providers. When applied to pediatric cohorts, adult-oriented instruments encounter severe ecological and construct invalidity. Primary school-aged children typically do not navigate formal healthcare settings independently, rarely possess comprehensive medical knowledge regarding diagnostic screening or prescription management, and operate structurally under parental, familial, and institutional authority.

Nevertheless, developmental psychology underscores that children aged 8 to 12 regularly execute pivotal lifestyle micro-decisions. Within school, domestic, and recreational settings, children make autonomous choices regarding nutritional consumption (e.g., selecting cafeteria foods, drinking water versus sweetened beverages), levels of physical activity, hygiene protocols, sedentary screen time, and adherence to sleep routines. When health promotion programs evaluate child outcomes, they historically rely upon crude biological markers (such as body mass index percentiles) or basic factual knowledge recall questionnaires. However, extensive behavioral literature demonstrates that factual health literacy rarely translates automatically into sustainable lifestyle change. What has been critically absent in pediatric preventive medicine is an intermediate outcome tool capable of measuring a child’s psychological readiness to act upon health knowledge.

The HAS-C directly bridges this gap. By offering a psychometrically rigorous, age-appropriate assessment tool, the instrument enables public health researchers to identify baseline levels of health agency in general pediatric populations. Clinically, it provides pediatricians, child psychologists, and community health nurses with a sensitive metric to evaluate how school-based lifestyle interventions alter a child’s motivational state. Rather than merely confirming that an educational module taught a child that physical exercise is beneficial, the HAS-C determines whether the child possesses the intrinsic valuation, situational confidence, and explicit behavioral intention required to engage in physical exercise independently.

Furthermore, the HAS-C serves a valuable diagnostic function in identifying pediatric subpopulations experiencing low agency or learned helplessness regarding their well-being. Identifying children with deficits in behavioral confidence or low intention for action enables targeted psychoeducational interventions tailored to their developmental readiness. Consequently, the scale acts as both an evaluative instrument for public health interventions and a diagnostic assessment tool for developmental and pediatric behavioral sciences.

5. Psychological Construct

Health activation within the pediatric context represents a multidimensional psychological construct that operationalizes a child’s developing autonomy, self-determination, and personal agency over daily health behaviors. The HAS-C delineates this latent meta-construct into three distinct yet structurally interrelated dimensions: Health Beliefs, Behavioural Confidence, and Intention for Action.

Health Beliefs

The Health Beliefs dimension evaluates the child’s internal value system concerning personal health, somatic well-being, and personal responsibility. Within this domain, health is operationalized not merely as the clinical absence of acute disease, but as an essential personal asset that requires deliberate maintenance. The psychological focus examines whether the child perceives health maintenance as an active responsibility belonging to themselves, rather than as a passive mandate enforced solely by parents, teachers, or pediatricians. A child with high scores in this dimension recognizes the fundamental connection between immediate behavioral choices and physiological outcomes, internalizing the belief that their daily actions directly influence how energetic, capable, and healthy they feel.

Behavioural Confidence

The Behavioural Confidence dimension measures situational self-efficacy—an individual’s subjective conviction in their operational capacity to execute healthy choices in real-world scenarios. In middle childhood, executing a healthy behavior frequently involves navigating environmental constraints, peer pressure, and competing hedonic rewards (such as choosing physical activity over sedentary digital entertainment, or selecting whole fruit over processed snacks). This subscale evaluates the child’s perceived competence to enact proactive choices, resist adverse temptations, and assert communication regarding their health needs (such as asking questions to adults when feeling unwell or requesting healthier meal options). High behavioral confidence signifies that the child feels psychologically capable of translating conceptual health awareness into tangible action despite external friction.

Intention for Action

The Intention for Action dimension assesses the proactive, goal-directed motivational readiness of the child to pursue healthy lifestyle modifications and acquire health information. Grounded in intentionality literature, this construct captures the prospective behavioral commitments made by the child. It evaluates whether the child actively plans to engage in regular physical exertion, expresses curiosity to learn more about nutritional wellness, and exhibits forward-looking motivation to maintain positive hygiene and lifestyle habits. While Health Beliefs establish the cognitive value of wellness and Behavioural Confidence assesses perceived capacity, Intention for Action represents the immediate motivational engine that precedes behavioral initiation.

During the developmental phase of the scale, an initial four-dimensional framework was hypothesized that included an explicit construct of Perceived Knowledge. However, empirical factor analytic modeling revealed that self-perceived knowledge items exhibited profound cross-loadings across confidence and belief dimensions. Cognitively, children aged 8 to 12 do not distinguish abstract self-perceived knowledge from their confidence to act or their general beliefs. Consequently, refining the construct into the three-factor architecture of Beliefs, Confidence, and Intention provides a parsimonious, robust operationalization of pediatric health activation.

6. Theoretical Framework

The conceptual architecture of the Health Activation Scale for Children integrates principles from three foundational psychological paradigms: Social Cognitive Theory, Self-Determination Theory, and the classical adult Patient Activation Model.

Social Cognitive Theory and Self-Efficacy

Central to the HAS-C is Albert Bandura’s Social Cognitive Theory, particularly the core mechanism of perceived self-efficacy. Bandura posited that individuals rarely attempt to initiate or sustain behaviors unless they believe they possess the internal capacity to produce desired outcomes. In pediatric populations, self-efficacy operates as a critical cognitive mediator between knowledge and action. A child may possess didactic knowledge regarding nutritional balance, yet remain inactive without sufficient situational confidence. Bandura also emphasized reciprocal determinism—the continuous bidirectional interaction between cognitive factors, behavioral patterns, and environmental influences. The HAS-C directly reflects this by assessing how internal beliefs and perceived confidence interact to produce actionable behavioral intentions within the child’s daily ecological context.

Self-Determination Theory and Emerging Autonomy

The progression of health activation is closely aligned with Edward Deci and Richard Ryan’s Self-Determination Theory (SDT). SDT posits that optimal behavioral functioning, persistence, and psychological well-being depend upon the satisfaction of three basic psychological needs: competence, relatedness, and autonomy. During middle childhood (ages 8–12), developmental trajectories shift from absolute dependence on parental regulation toward co-regulation and autonomous agency. According to SDT’s organismic integration continuum, external regulations (e.g., parental commands to brush teeth or eat vegetables) gradually undergo introjection, identification, and integration into the child’s core self-concept. The HAS-C’s Health Beliefs and Intention for Action subscales directly operationalize this internalizing process, capturing the degree to which a child experiences health maintenance as an internally endorsed, autonomous value rather than an externally imposed chore.

Adaptation from Adult Activation Paradigms

The broader construct of activation originates from Judith Hibbard and colleagues, who formulated the Patient Activation Measure (PAM). Hibbard defined activation as a developmental continuum traversing four progressive developmental stages: (1) believing that an active role is important, (2) possessing the knowledge and confidence to take action, (3) actively taking action to maintain health, and (4) maintaining behaviors under stress. The HAS-C synthesizes Hibbard’s developmental continuum while removing adult clinical requirements (such as understanding medication regimens, evaluating clinical specialists, or parsing diagnostic results). Instead, the HAS-C preserves the developmental logic of activation—progressing from cognitive valuation (Health Beliefs) through personal agency (Behavioural Confidence) to goal-directed commitment (Intention for Action)—within the developmental realities of primary school students.

7. Validity

Psychometric evaluation of the Health Activation Scale for Children has yielded strong evidence supporting its internal structural validity, construct dimensionality, and developmental appropriateness.

Content and Structural Validity

Content validity was established through systematic item generation derived from comprehensive reviews of pediatric health literacy, health promotion literature, and expert panel evaluations. A pool of candidate items was crafted using simplified syntactic structures and vocabulary tailored for reading comprehension among 8- to 12-year-olds. The structural integrity of the scale was tested via both exploratory and confirmatory factor analyses. The initial hypothesized 21-item questionnaire contained four theoretical dimensions (Perceived Knowledge, Health Beliefs, Behavioural Confidence, and Intention for Action). Statistical modeling revealed that items intended to measure ‘perceived knowledge’ failed to establish discriminant validity, displaying substantial cross-loadings across behavioral confidence and health belief constructs. Elimination of psychometrically unstable and redundant items yielded an optimized 12-item, three-factor structure.

Confirmatory Factor Analysis (CFA) Model Fit

Confirmatory factor analysis conducted on the 12-item model confirmed that the three-factor solution demonstrated exceptional fit with empirical data collected from primary school children in Singapore. Multiple rigorous goodness-of-fit indices supported the structural validity of the construct:

• Comparative Fit Index (CFI): .968 (exceeding the standard $ge .95$ criterion for excellent model fit)
• Tucker-Lewis Index (TLI): .954 (surpassing the conventional $ge .95$ benchmark)
• Root Mean Square Error of Approximation (RMSEA): .044 (well below the $le .06$ threshold representing close approximate fit; 90% CI [.025, .062])
• Normed Chi-Square: $\chi^2 / df = 1.583$ (comfortably below the conservative ceiling of 2.0 or 3.0)

All standardized factor loadings for the 12 items on their respective latent variables were statistically significant ($p < .001$) and exceeded the psychometric threshold of > .35, indicating that each manifest variable contributed meaningfully to its designated construct.

Convergent and Discriminant Properties

Inter-factor correlations among the three latent dimensions (Health Beliefs, Behavioural Confidence, and Intention for Action) demonstrated moderate-to-strong positive associations, supporting theoretical convergence while confirming discriminant validity. The subscales measure distinct facets of activation rather than redundant psychological traits. Furthermore, the instrument demonstrated sensitivity across age cohorts, documenting progressive increments in health activation scores matching cognitive and developmental maturity across the 8 to 12 age range.

8. Reliability

The Health Activation Scale for Children possesses robust internal consistency across the total composite scale and acceptable reliability across each of its 4-item subscales.

Internal Consistency Metrics

Reliability parameters evaluated within the primary validation study ($N = \text{primary school cohort in Singapore}$) yielded the following psychometric indices:

• Overall HAS-C Composite Scale (12 items): Cronbach’s $\alpha = .844$. This value surpasses the recognized standard of .80 for established psychological measurement tools, confirming that the 12 items function with high internal homogeneity to measure the global construct of pediatric health activation.
• Intention for Action Subscale (4 items): Cronbach’s $\alpha = .753$. Demonstrates good internal consistency for a brief, 4-item pediatric subscale.
• Health Beliefs Subscale (4 items): Cronbach’s $\alpha = .732$. Reflects solid internal reliability for assessing cognitive valuation of wellness.
• Behavioural Confidence Subscale (4 items): Cronbach’s $\alpha = .698$. While bordering the standard .70 psychometric threshold, this level of internal consistency is considered acceptable and methodologically expected given the developmental heterogeneity of self-efficacy appraisals among younger primary school children and the concise 4-item length of the subscale.

Scale Brevity and Error Variance

In classical test theory, Cronbach’s alpha is inherently dependent on the total number of items included within a scale. Because each subscale within the HAS-C deliberately contains only 4 items to minimize respondent fatigue and cognitive burden in children aged 8–12, alpha coefficients ranging between .70 and .75 reflect strong item-to-subscale correlations and low measurement error. Item-total correlations across all 12 items confirmed that each individual indicator contributed positively to composite scale reliability without redundant collinearity.

9. Factor Analysis

The internal structural validation of the HAS-C was achieved using an iterative, two-stage factor analytic strategy combining Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA).

Exploratory Factor Analysis (EFA)

Initial instrument development generated an item pool of 21 manifest items designed to capture four theoretical domains: Perceived Knowledge, Health Beliefs, Behavioural Confidence, and Intention for Action. An exploratory factor analysis utilizing principal axis factoring and oblique Promax rotation (accounting for theoretical correlations among activation dimensions) was conducted on the candidate pool. The EFA revealed significant psychometric instability surrounding the ‘Perceived Knowledge’ domain; these items exhibited notable cross-loadings across both the Behavioural Confidence and Health Beliefs factors, lacking unique structural variance.

Through systematic psychometric item refinement—removing items that demonstrated poor primary factor loadings (< .35), significant cross-loadings (> .30 on secondary factors), or conceptual redundancy—the instrument was refined down to an optimized 12-item inventory. A subsequent EFA performed on the 12 items extracted three clean, distinct factors with eigenvalues exceeding 1.0, accounting for substantial common variance. Exactly four unique items loaded cleanly onto each of the three extracted dimensions:

• Factor 1 (Behavioural Confidence): Items 3, 4, 10, and 18.
• Factor 2 (Intention for Action): Items 5, 8, 11, and 21.
• Factor 3 (Health Beliefs): Items 12, 13, 14, and 15.

Confirmatory Factor Analysis (CFA)

The refined three-factor, 12-item model was subsequently evaluated using Confirmatory Factor Analysis. Parameter estimation demonstrated that all 12 items loaded significantly on their designated latent factors ($p < .001$), with standardized factor loadings ranging above .35, verifying clear indicator specification. Goodness-of-fit modeling confirmed that the hypothesized three-factor architecture captured the underlying data structure:

These structural findings support the tripartite conceptualization of pediatric health activation, demonstrating that children evaluate health choices through the combined lenses of what they value (beliefs), what they feel able to do (confidence), and what they plan to enact (intention).

10. Instrument / Measurement Tool

• Complete Tool Name: Health Activation Scale for Children (HAS-C)
• Assessment Type: Self-report psychological measurement scale / Survey questionnaire
• Target Population: Primary school children
• Target Age Cohort: 8 to 12 years of age
• Administration Modality: Self-administered (paper-and-pencil or digital self-completion with supervised assistance if required for reading comprehension)
• Total Item Count: 12 items
• Subscale Architecture: 3 multidimensional factors (4 items per subscale):
  • Behavioural Confidence: Items 3, 4, 10, 18 (evaluating perceived self-efficacy in executing healthy habits and communicating health needs)
  • Intention for Action: Items 5, 8, 11, 21 (evaluating prospective motivation and willingness to adopt healthy behaviors and seek knowledge)
  • Health Beliefs: Items 12, 13, 14, 15 (evaluating personal valuation of physical health and internal locus of responsibility)
• Authentic Response Scale: 12 items, 4-point Likert scale (Strongly Disagree to Strongly Agree):
  • 1 = Strongly Disagree
  • 2 = Disagree
  • 3 = Agree
  • 4 = Strongly Agree
• Scoring Instructions: Items are summed or averaged to yield subscale and total scores. Higher scores indicate greater levels of health activation. Subscale scores are derived by calculating the mean or sum of their respective four items (range: 4–16 for summed subscores, or 1.0–4.0 for averaged subscores). The overall health activation composite score is calculated by summing all 12 items (range: 12–48) or by averaging all 12 items (range: 1.0–4.0).
• Original Language: English
• Validation Sample Characteristics: Primary school students aged 8 to 12 in Singapore ($N$ roughly evenly distributed by sex: 50.1% boys, 49.9% girls; multi-ethnic distribution: 64.8% Chinese, 14.7% Malay, 9.2% Indian, and other ethnicities).

11. Permissions & Fee and Test Year

• Year of Initial Publication: 2024
• Original Academic Publication: Published in BMC Health Services Research (https://doi.org/10.1186/s12913-024-11526-7).
• Licensing and Open Access Status: The original validation research article is distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0). However, the complete individual questionnaire items of the scale are protected and are not fully reproduced within the open public domain text of the source paper.
• Usage Permissions: Academic researchers, clinical psychologists, and public health evaluators seeking to access, administer, or translate the official 12-item HAS-C instrument must contact the corresponding author directly for scale materials and usage guidelines:
  
  Dr. Lixia Ge
  Health Services & Outcomes Research, National Healthcare Group, Singapore.
  Email: [email protected]
• Commercial and Administrative Fees: Academic and non-profit educational research uses typically require written authorization without commercial licensing fees. Commercial or sponsored trials must clarify proprietary permissions with the author and institutional copyright holders.

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13. Items of the Scale