Healthy Aging Activity Engagement Scale

1. Abstract

The Healthy Aging Activity Engagement Scale (HAAE) is a comprehensive psychometric instrument engineered to evaluate proactive, multidimensional engagement in health-promoting behaviors among middle-aged and older adults. Moving beyond traditional, deficit-focused biomedical paradigms that conceptualize aging strictly in terms of morbidity, functional decline, and physical limitations, the HAAE operationalizes healthy aging as an active, integrated lifestyle process. The instrument comprises 32 items structured across three core multidimensional factors: physical health behaviors, cognitive and social enrichment, and psychological well-being and stress regulation. This detailed evaluation tool captures the frequency, breadth, and intensity of proactive health practices across the adult lifespan.

Originally conceptualized in gerontological literature by Schmitter-Edgecombe et al. and cross-culturally translated and adapted for mainland Chinese populations by Lu, Kong, and Zhang (2022) using the Brislin double-translation model, the scale underwent rigorous psychometric evaluation among 424 middle-aged and older adults (aged 45 years and older; mean age cohort inclusive of 62.7% aged 60 and above). The scale demonstrated exceptional internal consistency, yielding an overall Cronbach’s alpha coefficient of 0.965 (frequently rounded to 0.97), with subscale internal consistencies ranging from 0.898 to 0.957. Test-retest reliability across a two-week interval was robust at r = 0.850, and split-half reliability reached 0.807. Structural equation modeling and Confirmatory Factor Analysis (CFA) affirmed the three-factor architecture with outstanding model fit parameters: Comparative Fit Index (CFI) = 0.982, Tucker-Lewis Index (TLI) = 0.981, Goodness-of-Fit Index (GFI) = 0.911, Root Mean Square Error of Approximation (RMSEA) = 0.030, and a chi-square to degrees of freedom ratio (χ²/df) of 1.393. Scale-level content validity index (S-CVI) reached 0.969. Consequently, the HAAE stands as an empirically validated, theoretically sound metric for preventive gerontology, clinical nursing, behavioral epidemiology, and community-based health intervention tracking.

2. Keywords

Healthy Aging, Activity Engagement, Psychometrics, Cross-cultural Validation, Gerontology, Preventative Health, Lifestyle Assessment, Biopsychosocial Model, Confirmatory Factor Analysis, Cognitive Enrichment

3. Authors

The cross-cultural adaptation, structural validation, and psychometric operationalization of the Chinese version of the Healthy Aging Activity Engagement Scale were conducted by clinical nursing and gerontological researchers at Jinzhou Medical University:

• Tingting Lu — Department of Nursing, Jinzhou Medical University, Jinzhou, Liaoning Province, China.
• Linghui Kong — Department of Nursing, Jinzhou Medical University, Jinzhou, Liaoning Province, China.
• Huijun Zhang (Corresponding Author) — Department of Nursing, Jinzhou Medical University, No. 40, Section 3, Songpo Road, Linghe District, Jinzhou 121001, Liaoning Province, China. Email contact: [email protected].

The foundational English-language prototype and theoretical architecture of the instrument trace back to developmental psychometric work by Maureen Schmitter-Edgecombe and colleagues at Washington State University (see Schmitter-Edgecombe et al., 2019).

4. Purpose

Historically, epidemiological and clinical assessments in gerontology have suffered from marked methodological fragmentation. Conventional assessment batteries routinely dissect adult behavior into isolated, non-interacting domains—deploying standalone physical activity questionnaires (such as the Physical Activity Scale for the Elderly), isolated nutritional screening tools, separate cognitive testing modules, and distinct perceived stress inventories. While these single-domain measures supply granular clinical data, they fail to account for the synergistic, ecological nature of human lifestyle patterns. Proactive behaviors do not function in clinical isolation; cognitive vitality, physical mobility, social connectedness, and psychological equilibrium mutually reinforce one another. The primary purpose of the Healthy Aging Activity Engagement Scale (HAAE) is to resolve this methodological disconnect by providing an integrated, unified psychometric instrument that evaluates multiple facets of health-promoting lifestyle engagement within a single, cohesive measurement framework.

The HAAE addresses critical preventative public health priorities, particularly in societies experiencing accelerated demographic transitions toward population aging. In nations such as China, where census data indicate an unprecedented surge in individuals aged 60 and older, the chronic disease burden poses substantial challenges for healthcare systems. The primary clinical utility of the HAAE lies in primary and secondary prevention: by administering the instrument to both middle-aged (45–59 years) and older adults (≥60 years), healthcare practitioners, community health workers, and geriatric nurse specialists can systematically detect lifestyle deficits years before the clinical manifestation of chronic morbidity, frailty syndromes, or dementia. Middle adulthood represents a pivotal neurobiological and cardiovascular window during which adverse habits (e.g., physical inactivity, unmanaged psychological distress, social isolation) initiate subclinical vascular and neurodegenerative cascades. Identifying low engagement levels across specific behavioral vectors allows clinicians to deliver targeted, personalized behavioral prescriptions.

From an applied research perspective, the HAAE provides a sensitive outcome measure for longitudinal lifestyle cohort studies and clinical trial interventions. When researchers implement multimodal healthy aging programs—combining physical exercise, intellectual challenges, and social community building—the HAAE serves as a reliable pre- and post-intervention assessment instrument. Its ability to capture subtle behavioral modifications across distinct yet interrelated factors renders it invaluable for quantifying treatment adherence, behavioral sustainability, and intervention efficacy across clinical, institutional, and community-dwelling settings.

5. Psychological Construct

The target construct measured by the HAAE is Multidimensional Healthy Aging Engagement. Rooted in the paradigm that optimal aging requires deliberate, proactive participation in life, the scale defines engagement not as passive trait resilience or spontaneous good fortune, but as intentional, sustained participation in activities proven to preserve somatic, neurocognitive, and socioemotional integrity. The 32 items operationalize this construct across three distinct yet interrelated latent dimensions:

Factor 1: Physical Health Behaviors

This dimension encompasses an individual’s active commitment to physiological preservation and somatic wellness. Moving beyond basic functional mobility, it captures routine engagement in moderate-to-vigorous aerobic activity, muscle-strengthening routines, balance maintenance, structured dietary regulation, sleep hygiene, and preventive somatic healthcare monitoring (e.g., routine physical examinations, blood pressure management, and medication compliance). In middle-aged and older populations, high engagement in this factor reflects an autonomous dedication to mitigating cardiovascular disease, sarcopenia, metabolic syndrome, and musculoskeletal decline.

Factor 2: Cognitive and Social Enrichment

This subscale assesses purposeful participation in novel, intellectually stimulating pursuits alongside reciprocal community and relational interactions. Cognitive enrichment includes activities that tax executive functions, working memory, and fluid intelligence, such as reading demanding literature, learning new digital skills, playing strategic games, engaging in creative arts, or solving complex problems. Social enrichment encompasses sustained participation in voluntary organizations, neighborhood peer groups, cultural gatherings, and family networks. In accordance with the cognitive reserve hypothesis, sustained stimulation through intellectual and social channels builds neural redundancy, mitigating the clinical manifestation of neuropathological changes associated with Alzheimer’s disease and vascular neurocognitive disorders.

Factor 3: Psychological Well-Being and Stress Regulation

This component captures proactive internal regulatory practices designed to foster psychological resilience, emotional equilibrium, life satisfaction, and stress reduction. Behaviors in this domain include active emotional coping strategies, mindfulness, recreational relaxation, spiritual or philosophical contemplation, and intentional avoidance of chronic stress triggers. Chronic psychosocial stress induces hypothalamic-pituitary-adrenal (HPA) axis dysregulation, elevating systemic pro-inflammatory cytokines and accelerating vascular endothelial damage. Individuals scoring high in this factor demonstrate deliberate utilization of stress-mitigation mechanisms, safeguarding psychological functioning, optimism, and biological homeostasis.

6. Theoretical Framework

The conceptual foundation of the Healthy Aging Activity Engagement Scale is anchored in three major theoretical frameworks within contemporary psychology, gerontology, and behavioral medicine:

The Biopsychosocial Model of Health

Pioneered by George Engel (1977), the Biopsychosocial Model posits that biological, psychological, and social factors exist in continuous, dynamic reciprocal interaction. Health cannot be conceptualized purely as the absence of biological disease. The HAAE directly operationalizes this model by assigning equivalent psychometric weight to somatic physical activities (biological), emotional regulation and cognitive exercises (psychological), and community participation (social). The model asserts that an intervention or behavioral deficit in one sphere inevitably ripples across the others: social isolation directly aggravates systemic inflammation, whereas physical exercise promotes neurogenesis and alleviates depressive symptomatology.

Rowe and Kahn’s Model of Successful Aging

Formulated by John Rowe and Robert Kahn (1987, 1997), this foundational gerontological model distinguishes “usual aging” (non-pathological but characterized by gradual functional decline) from “successful aging.” Rowe and Kahn proposed that successful aging comprises three fundamental components: (1) low probability of disease and disease-related disability, (2) high cognitive and physical functional capacity, and (3) active engagement with life. The HAAE specifically targets the third, most actionable component: active engagement. Under this framework, having the physiological capacity to function is insufficient; an individual must purposefully mobilize those capacities through interpersonal relationships and productive, meaningful activities.

Activity Theory of Aging

Originally conceptualized by Robert Havighurst and colleagues, the Activity Theory of Aging contends that older adults who remain actively involved in social, mental, and physical activities achieve higher levels of subjective well-being, psychological satisfaction, and functional longevity. Rather than gradually disengaging from social roles and challenging pursuits (as posited by early disengagement theories), optimal aging necessitates the maintenance of existing roles or the adoption of new, cognitively vibrant, and socially valuable substitutes.

7. Validity

The psychometric validity of the Healthy Aging Activity Engagement Scale was systematically verified through multiple empirical stages during its cross-cultural adaptation and testing among 424 middle-aged and older Chinese participants (Lu et al., 2022):

Content and Translation Validity

To preserve semantic, idiomatic, experiential, and conceptual equivalence, the translation protocol strictly followed the Brislin double-translation model. This process entailed forward-translation by independent bilingual translators, synthesis, back-translation by blind linguists, and evaluation by a specialized multidisciplinary expert panel comprising geriatricians, behavioral psychologists, and nurse researchers. Content validity was quantified utilizing the Content Validity Index (CVI). The Scale-Level Content Validity Index (S-CVI) achieved a notable 0.969, while Item-Level Content Validity Indices (I-CVI) across the 32 individual items ranged from 0.833 to 1.000, substantially surpassing the psychometric benchmark of 0.80 established by Polit and Beck. These metrics confirm that the translated scale items comprehensively and accurately operationalize the theoretical construct within the cultural context of mainland China.

Construct and Structural Validity

Construct validity was demonstrated through a dual-phase exploratory and confirmatory factor analytic strategy. Both phases confirmed that the observed covariances among the 32 items converged into three theoretically coherent dimensions. Factor loadings across all items exceeded the conservative threshold of 0.40 (ranging up to 0.80+), indicating robust convergent validity within each sub-dimension. High inter-factor correlations coupled with distinct subscale factor structures established strong discriminant validity, showing that while physical, cognitive-social, and psychological domains covary as components of healthy aging, they represent empirically distinct behavioral domains.

Criterion-Related and Predictive Utility

Consistent with extensive literature on lifestyle engagement, scores on the HAAE demonstrate strong negative correlations with indices of frailty, functional dependency, depressive symptoms, and perceived stress, alongside strong positive associations with health-related quality of life, self-efficacy, and physiological vitality markers. These findings substantiate the criterion validity of the instrument as an indicator of functional status and preventive lifestyle adoption.

8. Reliability

Reliability evaluations demonstrate that the HAAE possesses high internal consistency, temporal stability, and measurement precision across its 32 items:

• Internal Consistency (Cronbach’s Alpha): The overall scale yielded a Cronbach’s alpha coefficient of α = 0.965 (often reported as 0.97 in summarized psychometric scorecards). This demonstrates high internal consistency. The individual subscales also exhibited strong internal consistency:
  • Factor 1 (Physical Health Behaviors): α = 0.957
  • Factor 2 (Cognitive and Social Enrichment): α = 0.923
  • Factor 3 (Psychological Well-Being and Stress Regulation): α = 0.898

  All subscale coefficients exceed the recommended 0.80 threshold for research and clinical diagnostic screening tools.

• Temporal Stability (Test-Retest Reliability): Stability across time was assessed by re-administering the instrument to a sub-sample of participants after a two-week interval under identical conditions. The resulting test-retest correlation coefficient was r = 0.850 (p < 0.001), indicating strong temporal stability and minimal measurement error attributable to short-term temporal fluctuations.
• Split-Half Reliability: The instrument demonstrated a split-half reliability coefficient of 0.807, further confirming the structural cohesion and internal balance between odd and even questionnaire items.

9. Factor Analysis

The structural integrity of the Chinese version of the HAAE was evaluated using a split-sample structural equation modeling approach that integrated Exploratory Factor Analysis (EFA) followed by Confirmatory Factor Analysis (CFA):

Exploratory Factor Analysis (EFA)

Prior to extraction, sampling adequacy and data suitability were confirmed using the Kaiser-Meyer-Olkin (KMO) metric and Bartlett’s Test of Sphericity. The KMO index yielded an optimal value (> 0.90), and Bartlett’s test was statistically significant (p < 0.001), verifying substantial shared variance among items. Principal component analysis with varimax orthogonal rotation was applied. In alignment with Kaiser’s criterion (eigenvalues > 1.0) and visual inspection of the scree plot, three prominent common factors emerged. Collectively, these three factors accounted for 63.448% of the total variance. Each of the 32 items exhibited primary factor loadings > 0.40, with no severe cross-loadings requiring item deletion, confirming the structural integrity of the 32-item design.

Confirmatory Factor Analysis (CFA)

Confirmatory factor analysis was conducted using maximum likelihood estimation to empirically test the goodness of fit of the theoretical three-factor model against the observed data. The analysis verified that the three-factor model had an excellent fit across standard psychometric indices:

• χ²/df (Chi-Square to Degrees of Freedom Ratio): 1.393 (Benchmark: ≤ 3.0 represents good fit; ≤ 2.0 indicates excellent fit).
• CFI (Comparative Fit Index): 0.982 (Benchmark: ≥ 0.95 indicates superior fit).
• TLI (Tucker-Lewis Index): 0.981 (Benchmark: ≥ 0.95 indicates superior fit).
• GFI (Goodness-of-Fit Index): 0.911 (Benchmark: ≥ 0.90 represents acceptable-to-good fit).
• RMSEA (Root Mean Square Error of Approximation): 0.030 with a 90% confidence interval falling well below 0.05 (Benchmark: ≤ 0.05 indicates close model fit).

The empirical verification of these fit indices confirms that the three-dimensional architecture of the HAAE is psychometrically robust and stable.

10. Instrument / Measurement Tool

The operational and administrative parameters of the Healthy Aging Activity Engagement Scale are outlined below:

• Test Type: Psychometric Self-Report Questionnaire / Patient-Reported Outcome Measure (PROM).
• Target Population: Community-dwelling, institutionalized, or outpatient adults and older adults.
• Applicable Age Bracket: Adults aged 45 years and older (spanning middle age, young-old, old-old, and oldest-old cohorts).
• Administration Mode: Self-administered (paper-and-pencil or digital survey platform) or interviewer-administered for individuals with visual, literacy, or motor impairments.
• Administration Duration: Approximately 8 to 12 minutes.
• Item Count: 32 items.
• Response Scale: Authentic 32-item multidimensional behavioral frequency rating scale. Participants rate the frequency and consistency with which they engage in each specified health, cognitive, and psychosocial behavior over a defined retrospective timeframe.
• Structural Subscales:
  • Factor 1: Physical Health Behaviors — somatic maintenance, active exercise, lifestyle regulation.
  • Factor 2: Cognitive and Social Enrichment — intellectual tasks, social networking, continuous learning, civic engagement.
  • Factor 3: Psychological Well-Being and Stress Regulation — adaptive coping, stress reduction, emotional balancing strategies.
• Scoring Protocol: Item scores are summed within subscales to provide specific factor scores and aggregated across all 32 items to generate a total Healthy Aging Engagement composite score. Higher total and dimension scores signify greater engagement in proactive behaviors that promote healthy aging. Clinicians can identify specific deficits by examining low factor scores.

11. Permissions & Fee and Test Year

The original English version of the Healthy Aging Activity Engagement Scale was developed and validated by Schmitter-Edgecombe et al. in 2019. The cross-cultural adaptation and psychometric validation for mainland China were conducted and published by Tingting Lu, Linghui Kong, and Huijun Zhang in 2022.

The validation study by Lu et al. was published as an open-access academic article distributed under the terms of the Creative Commons Attribution License (CC BY) in Frontiers in Public Health. However, while the research article itself is open access, the complete 32-item questionnaire is protected by academic copyright. The authors and affiliated university maintain intellectual custody of the full instrument to preserve psychometric standardization and ensure appropriate clinical translation.

Academic researchers, healthcare institutions, and clinicians may utilize the scale for non-commercial research, academic inquiry, and clinical assessment without paying licensing fees, provided formal permission is requested and granted. Researchers interested in obtaining the complete Chinese or English item inventories, scoring keys, and administrative manuals should contact the corresponding author directly:

• Corresponding Author: Prof. Huijun Zhang
• Institution: Department of Nursing, Jinzhou Medical University, Jinzhou, Liaoning, China
• Official Correspondence Email: [email protected]

12. References

The following peer-reviewed publications and foundational works provide the psychometric and theoretical foundations for the Healthy Aging Activity Engagement Scale:

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13. Items of the Scale