Development of the Healthy Aging Perspectives Questionnaire among Older Adults with Chronic Disease in Taiwan

Wang, Yu-Rung; Lee, Huan-Fang; Hsieh, Pei-Lun; Chen, Ching-Min

doi:https://doi.org/10.1155/2023/8238748

Health & Social Care in the Community

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Abstract Introduction Methods Results Discussion Conclusions Data Availability Conflicts of Interest Acknowledgments Supplementary Materials References Copyright Related Articles

Research Article | Open Access

Volume 2023 | Article ID 8238748 | https://doi.org/10.1155/2023/8238748

Development of the Healthy Aging Perspectives Questionnaire among Older Adults with Chronic Disease in Taiwan

Yu-Rung Wang,¹Huan-Fang Lee,²Pei-Lun Hsieh,³and Ching-Min Chen²

Academic Editor: Tommaso Martino

Received16 Nov 2022

Revised30 Mar 2023

Accepted01 Apr 2023

Published18 Apr 2023

Abstract

The purpose of this study was to develop a questionnaire which investigates perspectives regarding healthy aging among old patients with chronic illness. This study used qualitative and quantitative methods, including in-depth interviews, focus groups, and surveys between 2014 and 2016. Participants were recruited from the outpatient department of a medical center and a community healthcare center, 23 for interviews and 332 for surveys. The exploratory factor analysis was applied to identify the domains of the questionnaire and reduce the number of scale items. Criterion validity and reliability were evaluated. The final instrument (19 items) comprised the following four domains affected by disease: physical and psychological changes; living environment changes; social relationship changes; and changes in family life. The instrument explained 62.71% of the total variance in healthy aging perspectives. Criterion validity was supported by a significant correlation of the questionnaire with the World Health Organization Quality of Life scale (r, range: 0.14–0.65). The internal consistency of the questionnaire was 0.8 (Cronbach’s α, range: 0.71–0.89). The questionnaire is a valid and reliable instrument useful for examining healthy aging perspectives in older adults with chronic diseases. To enhance healthy aging for older persons with chronic disease, policy makers should acknowledge that elderly with chronic diseases not only have healthcare needs but also need attention regarding their psychological health and social and environmental relationships. The healthy aging perspectives questionnaire (HAPQ) can help clinicians to determine how to approach their older patients with chronic diseases to promote healthy aging.

1. Introduction

The World Health Organization (WHO) initially proposed the Healthy Ageing Policy in 2015. However, given the impact of the pandemic, the WHO published the United Nations Decade of Healthy Ageing (2021–2030) in 2021, this time attaching greater importance to healthy aging. According to the United Nations [1], the proportion of people aged 65 and above has increased from 6% in 1990 to 11% in 2019. Moreover, it is expected to increase to 16% by 2050 in Eastern and South-Eastern Asia.

The scenario is similar in Taiwan, except that the percentage of older persons aged 65 and above reached 14% in 2018 [2] and is estimated to increase to 20% by 2025 [3]. Taiwan ranks number one worldwide for its rapid increase in the aging population. As the aging population has become a major socioeconomic concern worldwide, policymakers have focused on promoting healthy and independent living among older people to enhance their contribution to social development and prevent aging from becoming a crisis for the healthcare system and for the social security of nations [4]. However, to successfully promote healthy aging among those with chronic diseases, it is important to be able to solicit their perspectives on healthy aging as a foundation to intervention.

The WHO reports that most people can expect to live up to age 60 and above. When people turn 60 years, it is estimated that they will live an average of 22 years more [4]. To avoid an epidemic of older adults with multiple chronic and debilitating conditions, healthy aging has become an important goal. Healthy aging is “the process of aging while developing and maintaining the functional ability that enables well-being in older age” [5]. When facing adaptation and compensation during the aging process, older persons can achieve healthy aging by enhancing their physical, social, and mental health to the maximum extent possible to facilitate their active roles in the society [6].

Although healthy aging is possible, it must be acknowledged that physiological changes occur as people age and risk of chronic conditions increases [5]. In Taiwan, the National Health Interview Survey has shown that more than 85% of Taiwan’s older adults suffer from at least one type of chronic disease [7]. Yet, healthy (or healthier) aging is possible even for these individuals. Older Taiwanese have benefited from the advancement of medical technology and implementation of National Health Insurance. Accessing medical services has become more convenient and affordable. National Health Insurance is commonly used by older persons with chronic diseases to cover the majority of their healthcare expenses, and statistics show that 93% of older persons visit outpatient services at least once per month [8, 9]. Howse [10] proposed that the successful promotion of healthy aging could be achieved only when the impact of chronic diseases on older persons was reduced to a minimum. This process requires the selection of proactive health and social care as well as better medical technology and health care systems for older persons.

Several studies have reported older persons’ perceptions of aging and the conditions of healthy aging [11–18]. Bacsu et al. noted that the factors related to healthy aging in place for older persons in rural Canada included social interaction, keeping active, independence, an optimistic mental outlook, and cognitive health [11]. Waites and Onolemhemhen reported that perceptions of healthy aging were influenced by culture. For example, African Americans’ perceptions of healthy aging were related to maintaining their independence, while Ethiopian older persons’ perceptions were related to the collective view of close family members [18]. Thiamwong et al. suggested that different cultural backgrounds should be considered to determine whether older persons in different regions of Thailand have different perspectives on aging [19]. Many adults and even healthcare providers view aging as a downward spiral of disease and loss of function, and do not appreciate that healthy aging is possible [20]. For the design of interventions to promote healthy aging, it is important to understand the perspectives of older adults on healthy aging. A reliable and valid instrument is required to determine these perspectives. The existing instruments do not adequately measure the full range of perspectives about healthy aging because they focus only on physical measures [21]. In addition, only limited research is available on what older people think about aging and how to achieve healthy aging. The purpose of this study was to develop and assess a comprehensive questionnaire to measure perspectives on healthy aging among older people with chronic diseases.

2. Methods

2.1. Aims

This study aims to develop the healthy aging perspectives questionnaire (HAPQ) for older people with chronic diseases. The qualitative aim is to investigate and confirm the perspectives on healthy aging among older adults with chronic diseases. The quantitative aim is the development of the scale from the qualitative approach results and to test the questionnaire’s psychometric properties.

2.2. Design

We used DeVellis [22] and Carpenter [23] suggestions and guides for the questionnaire development. We collected two sets of data for the following two separate stages: (1) investigation of the perspectives on healthy aging among older adults with chronic diseases using a qualitative descriptive study design (including focus groups and individual interviews) and application of inductive content analysis for confirming the perspectives of healthy aging themes and (2) development of the questionnaire from the results of the qualitative descriptive study and testing the psychometric properties of the questionnaire.

2.3. Sample/Participants

For the qualitative and quantitative studies, participants were recruited from a general outpatient department of a medical center and community health care service in southern Taiwan from 2014 to 2016 upon referral from their attending physicians. The inclusion criteria were as follows: (1) patient had at least one chronic disease as defined by the WHO [24]; (2) aged 60 years or older; and (3) able to communicate in Mandarin or Taiwanese. Purposeful sampling was used for both stages of the study. Different individuals were recruited for each of the studies (i.e., qualitative descriptive, focus groups, and quantitative study).

2.4. Data Collection

2.4.1. Qualitative Study

The researchers explained the purpose of the study, and if the participants agreed and were willing to share their perceptions, they were invited to participate and signed an informed consent form. In our qualitative approach, we employed focus group discussions and in-depth interviews, which were conducted at a medical center and community health care service.

An open-ended interview guide was used for both the focus groups and the individual interviews to investigate perceptions of healthy aging among older persons with chronic diseases. The following questions were used as the initial prompts in the interviews and focus groups: (1) What do you think healthy ageing is and what do you think about healthy ageing? (2) How do you face or cope with and adapt to the ageing process when you have a chronic disease? (3) How do you think your past and current health conditions affect your belief in your ability to achieve healthy ageing? (4) What kinds of changes have you experienced as you aged? (5) How do you adjust to the ageing process?

To ensure the rigor of the study, we followed the four criteria for doing so [25], including credibility, dependability, transferability, and confirmability. First, credibility was demonstrated, as the researchers had extensive experience in the care of older people, had received training in the qualitative research and participated in all aspects of the research process. All interviews were audio-recorded and transcribed within 24 hours, and the facial expressions and physical behaviors of the participants were also noted in field notes and included in the transcriptions. Second, the first author conducted semantic coding of transcripts, and then peer debriefing was held, involving discussion with the other researchers. The debriefing was followed by classifications and conclusions to guarantee dependability.

Third, transferability was established by identifying participants through purposive sampling and the collection of comprehensive data that were representative enough to be translated to similar situations and studies. Finally, the text provides context for the informational content through detailed descriptions and procedural transparency. To enhance the confirmability of the data analysis, if the classification of the theme was not clear, confirmation was sought from the participants. The complete text files and raw data, including the audio files, notes taken in the interviews, and analyzed records for review were kept and are available for use in the future.

2.4.2. Quantitative Study

A quantitative survey of the 21-question of HAPQ was based on three components: the healthy aging model proposed by the World Health Organization [5], the healthy aging theory proposed by Ryff and Singer [26], and the qualitative interview results in this study. Each item on the HAPQ was scored on a 5-point Likert scale, with the following ascribed meanings: 1, complete disagreement; 2, disagreement; 3, no opinion; 4, agreement; and 5, strong agreement. Higher scores indicate better perspectives of healthy aging. We invited ten experts representing different areas of expertise (five gerontology experts, two geriatric clinical care experts, two health care policy experts, and one psychologist) to review five grades of content serviceability and writing clarity. The result of the expert validity testing (content validity index, CVI) was 0.8–1. The acceptable values of the content validity index should be higher than 0.8 [27]. Following confirmation of the HAPQ items by the expert reviewers, older adults from the outpatient department were invited to participate in our psychometric testing and 332 were recruited. According to Comrey and Lee [28] an adequate sample size for performing factor analysis is no less than 300, thus our study was adequately powered.

2.5. Measures

Following the WHO healthy aging model [5], which included environmental and intrinsic capacity influenced by quality of life (QOL), we used the World Health Organization Quality of Life (WHOQOL) for criterion validity evaluation of the HAPQ.

The WHO developed this scale to assess QOL. WHOQOL-Brief is a simplified 26-item version of the WHOQOL-100 [29]. The Taiwan version of the WHOQOL-Brief added two items relevant to the local culture. The final 28 items were scored on a 5-point Likert scale (from the lowest score of 1 to the highest score of 5) [29]; a higher score is considered a better QOL. The scale includes four domains: physical health (7 items), mental health (6 items), social relations (4 items), and environment (11 items). The validity and reliability were described in the Taiwan version, and the testing contained internal consistency of the scale (Cronbach’s α = 0.70–0.77 for each dimension, total Cronbach’s α = 0.91), test-retest reliability (r = 0.76–0.80), and structural validity (exploratory factor analysis of four factors and 73% variance explanation; comparative fit index = 0.89).

2.6. Ethical Considerations

All study procedures were approved by the Institutional Review Board in Taiwan (registration number 10208–012). Participants were asked to sign and return their inform consent before the interviews began. The participants were also told that they could withdraw their consent and discontinue participating in the study at any time during the data collection process. They were also able to ask to stop recording or leave during the interview, and these decisions did not affect their right to medical care.

2.7. Data Analysis

2.7.1. Qualitative Study

Prior to the data analysis, the first author conducted semantic coding of the transcripts. Subsequently, the first and fourth authors conducted data analysis and classification. Both the researchers are proficient in Taiwanese and Mandarin. They give comments on intonations from participants’ video records. The notes taken at the interviews were also used to accurately understand the extracted meaning of the interview content to explore the implications of the language interactions.

A qualitative inductive content analysis method, influenced by Graneheim and Lundman [30], was applied to the interview text. Two researchers used Microsoft Excel and NVivo 10 software for the analysis process. The raw data were first transformed into meaning units, and then, in the induction process, independent fragments of information were compared and integrated. Next, the fragments of information were compiled and fit together like puzzle pieces. Finally, themes were generated with a latent approach, and the categories were developed with a manifest approach. Appropriate quotations were selected to express the content. If the theme was unclear during the classification process, the researchers confirmed their thoughts from the participants again.

2.7.2. Quantitative Study

Item analysis, exploratory factor analysis, internal consistency, and criterion validity were applied to test the psychometrics of the scale. First, the item analysis was adopted based on descriptive statistics and the independent-sample t-test for testing the critical ratio (CR). The first 27% of participants and the last 27% of participants of the total scale scores were divided into the high-score and low-score groups. Suitable data quality is indicated by an absolute value greater than three; a statistically significant difference should be reached between the two groups as well [31]. Following this, item reduction and factor extraction were performed by the exploratory factor analysis (EFA) using IBM SPSS version 22.0. The EFA was carried out using the principal component analysis and Promax rotation to explore the new structure of the scale. There were some indicators for detecting data suitability before testing. When examining item quality by the item analysis, the values of Bartlett’s test of sphericity [32] and Kaiser-Meyer-Oklin (KMO) should be greater than 0.8 [33]. Items were excluded based on their Communalities after extraction value (>0.5) [34]. After deleting unfit items, we performed the factor analysis again, reviewed the steps described previously, used the rotation component matrix to determine the factors, and named the new factors. Then, we checked whether the eigenvalues of the factor were greater than 1 and each item factor loading was greater than 0.3 [22] to decide whether to delete the item or not. We then performed the tests for reliability and validity. Cronbach’s alpha (α) was used to test for internal consistency of the subscales and the overall scale, and the criteria were over 0.7 [35]. The WHOQOL scale was used to examine the criterion validity.

3. Results

3.1. Qualitative Study

Three female and three male patients participated in in-depth interviews, and fifteen female and two male patients participated in the three focus group discussions. Their demographics are shown in Table 1. The verbatim transcripts from the six in-depth interviews and three focus groups indicated that healthy aging could be viewed from the perspectives outlined and quotes in Table 2. The interviews and focus groups yielded the following four themes: (1) physical health; (2) psychological health; (3) social and family relationships; and (4) living environment. The HAPQ was structured to represent these four domains.

3.2. Quantitative Study

The study included 332 participants with an average age of 70.8 years and a standard deviation of 7.78. On average, these older Taiwanese had 1.8 types of chronic diseases (±1.0), with hypertension being the most common (56%), followed by diabetes (48%). Among other characteristics, most participants graduated from junior high school or below (74.1%), were unemployed (66%), married (94.6%), had an income of less than 20,000 NT$ (approximately USD 645) per month (53.9%), and were living with their children (61.4%). The mean total score of the HAPQ was 3.34 (±0.42), and the mean scores of the four subscales ranged from 2.67 to 3.71 (Table 1).

3.2.1. Quality of Items

The mean scores of the high and low-score groups differed significantly (). Furthermore, the absolute t-value was greater than 3, indicating good discrimination (Table 3).

3.2.2. Item Reduction and Factor Extraction

Before performing the analysis, we examined the results of KMO = 0.84 and Bartlett’s test of sphericity, where Chi-square = 3102, df = 171, , showing that it was suitable for EFA. We examined the eigenvalue (>1), community extraction value (>0.32), and the scree plot to decide upon deleting two items (16, 19) due to factor loading being less than 0.3. Finally, we decided on the four factors and 19 items of the questionnaire (Appendix 1). They were distinguished and named as the physical and psychological changes caused by disease (6 items), the living environment changes caused by the disease (5 items), social relationship changes caused by disease (3 items), and changes in family life caused by disease (5 items) (Table 4). The scale explained 62.71% of the total variance.

3.2.3. Validity

The criterion validity for testing the questionnaire was established by using WHOQOL. The correlation coefficient among the four dimensions ranged from 0.08 to 0.65. The WHOQOL was positively correlated with the four dimensions (Table 5).

3.2.4. Reliability

The overall scale had a Cronbach’s α of 0.8. The internal consistency for all subscales was satisfactory, with Cronbach’s α ranging from 0.71 to 0.89 (Table 4). All corrected item-total correlations surpassed 0.3, representing a good fit with the questionnaire.

4. Discussion

An exploratory sequential mixed-methods design was applied in this study to develop an instrument, the HAPQ, from qualitative and quantitative data. In terms of the qualitative data, perspectives on healthy aging were obtained from older adults with chronic diseases through focus groups and in-depth interviews. Four themes were found that included physical, psychological, social and family relationships, and environmental aspects. Based on these qualitative results, the WHO’s Healthy Aging Model, and the healthy aging theory proposed by Ryff and Singer [26], a 19-item HAPQ for older adults with chronic diseases was developed. During the process, the expert suggestions and the results of the pilot study served as the basis for the finalized version of the HAPQ. Nineteen items in total covered the following four domains: (1) physical and psychological changes caused by the disease, (2) the living environment changes caused by the disease, (3) social relationship changes caused by the disease, and (4) changes in family life caused by the disease, which demonstrated good reliability and validity.

Based on the results of two longitudinal, cohort studies on healthy aging conducted [21, 36], it was found that existing research focused on the physiological indicators and focused less on the development of the scale from the complete model of the World Health Organization [5]. Therefore, our study began with the qualitative research and summarized four themes from the content analysis of the interview results, which were found to be similar to the results of the qualitative research conducted by Seah et al. [15], who explored the achievement of healthy aging through a sense of coherence among Chinese elders in Singapore. The Chinese older people similarly that the focus of life should shift back from children to themselves, and activities with the spouse should increase to reduce disputes between families. The results of both studies showed there were similar conflicts with children and mutual dependence between the husband and wife. In addition, it was found that even in the face of physical diseases, older adults would have physical and psychological reactions that affected their perspectives on healthy aging in Taiwan and Singapore. Despite the restrictions imposed by filial piety on family relationships between the Chinese and with rapid social changes, children’s responsibilities and their parent-child relationships have changed as well [37]. Although half of older adults in Taiwan would expect to live with their children [38], older adults still thought that if they cared too much about their children, they would have more inner conflicts.

The items of the HAPQ were drafted based on the qualitative results. Data collection was carried out after expert validity and pilot study, and the framework of the scale was constructed through data quality review and factor analysis. The research results fit the healthy aging model proposed by the WHO [5], including two significant domains of intrinsic capacity and environment. The criterion validity test was carried out using the four domains based on the speculation that there existed a positive correlation between good healthy aging perspectives and the concept of QOL among older adults with chronic diseases. The WHOQOL was employed to perform the criterion validity test, and the results showed that most of the four domains of the scale were positively correlated with their own domains, indicating that the better the perspectives on healthy aging, the better the QOL among the older adults with chronic diseases. The results echoed the physical and emotional health component and functional ability component proposed by Ayala et al. [39]; they were similar to the findings that physical activities, social support, and optimistic attitude were correlated with the QOL in the study conducted by Cyarto et al. [12]. Meanwhile, the results were also close to the findings that health perception relationship, attitude, and adaptation were correlated with the QOL among older adults through the thematic synthesis analysis [40]. In addition, we found that physical and psychological changes were most highly correlated with QOL, followed by changes in family life. These findings were similar to the findings of the study conducted in Thailand by Manasatchakun et al. [41], who showed that family relationships and physiological conditions had a higher correlation with healthy aging.

5. Limitation

There are some limitations to our study. First, the study population was selected from Taiwan alone. Second, all of the older persons included in the study group were those with better daily functioning who took the initiative in seeking medical treatment in the hospital. Furthermore, our study did not include disabled older persons with chronic diseases, and a cross-sectional study design was applied in this study for sample collection. Furthermore, the interview questions and questionnaire were developed in Taiwanese and Mandarin, which could be a limitation.

6. Conclusions

We conducted a comprehensive and novel exploration of the perspectives of healthy aging among older persons with chronic diseases and developed a measurement tool in Taiwan. The results indicated that physiological health, psychological health, social and family relationships, and living environment play key roles. Moreover, we developed the HAPQ, which has good reliability and validity. Older persons believe that undergoing the aging process is a natural phenomenon, and with health care provided under the National Health Insurance System in Taiwan, they can self-adapt, modify their previous lifestyles and thoughts, and thus reach the goal of successful healthy aging. This knowledge may help nurses develop strategies to support these individuals by building a supportive environment and enhancing their family relationships. Further research is needed to understand and evaluate nursing interventions to promote healthy aging among Taiwanese older persons with chronic.

Data Availability

Data used to support the findings in this study are available on request from the corresponding author.

Conflicts of Interest

The authors declare that they have no conflicts of interest with respect to the research, authorship, and/or publication of this article.

Acknowledgments

The authors would like to acknowledge and thank Dr. Debra K. Moser and Dr. Kaitlin Voigts Key for their consultation throughout the duration of paper writing. This work was supported by the Chi Mei Medical Center under CMFHR no. 10369.

Supplementary Materials

Appendix 1: the healthy aging perspectives questionnaire. (Supplementary Materials)

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Copyright © 2023 Yu-Rung Wang et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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