Development and psychometric evaluation of the healthy lifestyle questionnaire for elderly (heal) | Health and Quality of Life Outcomes

Since the beginning of the twenty-first century, improved living conditions and life expectancy have resulted in an increase in the population of older adults worldwide. For instance, it has been reported that between 2015 and 2030 the older population in lower-middle income countries will increase by 66% and that in low-income countries will grow up by 63% [1]. However, as far as it relates to Iran, the official statistics indicates that the population of older adults is increasing steadily. At present about 10% of the population of Iran are aged 60 and over [2, 3].

Owing to the accelerated phenomenon of population aging in Iran as in other countries, demographic conditions are changing and moving toward aging and its resultant consequences [4]. These changes will most likely lead to important economic, health, and social challenges, and a growing prevalence of chronic conditions will increase the need for health improvement interventions by healthcare providers as well as family members and communities. It must be noted that modification and improvement of lifestyle are important prerequisites for maintaining good health [5] Given the growth in chronic conditions and, based on the health promotion approaches, people must be empowered to accept responsibility for their own health and adopt a healthy lifestyle [6].

A healthy lifestyle with the multidimensional nature is crucial, as it can influence the quality of life, illness management, and prevent diseases [7]. A healthy lifestyle means having a balanced life in which an individual consciously makes healthy choices and takes special measures such as following a healthy diet, striking a balance among sleep, activity, and exercise, controlling weight and stress, abstaining from smoking and consuming alcohol, and getting oneself immunized against diseases [8]. However, though lifestyle is formed by personal choices and identities, it cannot be analyzed in isolation of its social and cultural contexts. It means the personal, biological and psychological characteristics of the individual, family, friends, and social community affect the individual’s daily life and lifestyle [9].

As there seems to be a triangular relationship between aging, chronic conditions, and healthy life style, the assessment of attitudes and behaviors of the elderly toward a certain lifestyle can offer information to healthcare providers to evaluate elders’ way of living and accurately design appropriate preventive interventions, enhance the capabilities of the elderly, and modify their lifestyle in an acceptable manner if necessary.

Assessment of the lifestyle of older people requires accurate tools for measuring health-related behaviors. Although there are numerous instruments for the measurement of lifestyle in Western communities, differences in social and cultural contexts, especially the ethnic backgrounds [9] and educational levels of older adults [10], might cause some limitations to their use in other communities such as Iran, where more than two-thirds of the elderly people are either illiterate or less educated [11]. Additionally some existing instruments only measure special lifestyle aspects for example, stress management, nutrition or exercise and do not have comprehensive approach to measuring healthy lifestyles.

Among existing instruments, the Health Enhancement Lifestyle Profile (HELP II), as a common multidimensional tool, has been applied in most lifestyle studies [12, 13]. The Iranian version of this questionnaire has been developed and mainly is used for young people [5, 8, 14,15,16,17].

Considering the limitations of using the existing tools in older adults, Eshaghi et al., in 2010, designed a Healthy Lifestyle Assessment Questionnaire for Iranian older adults. This questionnaire was designed based on a review of available tools, relevant texts, and interviews with Iranian elderly population. It includes 46 Likert type questions, which are designed to assess physical activity, sport and recreation, healthy eating, stress management, and social and interpersonal relationships in older adults [18]. This questionnaire is long and the response categories are very diverse and sometimes could be difficult to understand and respond to its items by elders.

According to Haywood et al., despite the presence of numerous instruments, it still is necessary to design and develop appropriate specific tools for screening and monitoring the health status and lifestyle of the elderly population. They argue that such tools must be simple, comprehensible, and easily applicable especially in clinical settings. In addition, as they should be more acceptable for and focused on the status of the elderly, they should be able to monitor and evaluate the changes in the elderly health status more precisely [18]. Spencer et al. believe that the evaluation of the health status of the elderly by the use of short questions and without clinical computation will facilitate the assessment of their health status and provide more valid and reliable data not only for healthcare providers but also for researchers [19].

Indeed, the nature of the aging process, some abilities, such as the loss of hearing, vision, concentration, and memory decline in older adults, can lead to problems in effective communication. Such problems make it difficult to use instruments with long and unclear statements for questioning older people. Given the lack of an appropriate tool to study the healthy lifestyle of the elderly population, it seems necessary to design instruments of acceptable validity and reliability that would be consistent with norms and social contexts, and be simple and easily applicable, especially to illiterate elders. Accordingly, the present study was designed to develop a questionnaire to study healthy lifestyles among older adults and evaluate its validity and reliability.

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