The translation process of the Culturally Sensitive Active Aging Scale for Community-Dwelling Older Adults in Pakistan

Abstract

Background: Active aging is define as older adults remaining active, connected, and contributing to society. To assess active aging in Pakistani elders, there is a scarcity of research tools to assess Active Aging levels in community-based older adults in Pakistan. Therefore, the aim of this study was to translate and validate the original English version of the Active Aging Scale into an Urdu version to measure active aging in community-based older adults in Pakistan.
Methods: We followed the guidelines of the International Society of Pharmacy Economic and Outcome Research (ISPOR) to translate the scale. The first phase consists of translation processes; the second phase is all about the validity and reliability of the scale. Construct validity, concurrent validity, and reliability were established for a 160-person sample of community-based older adults. The finding of test-retest reliability was performed after a two-week interval on the remaining 30% of the sample. For concurrent validity, the Successful Aging Scale (SAS) Urdu version was used as the gold standard and applied at the same time on the same sample. Data were analyzed in SPPSS version 23, and AMOS version 23.
Results: Our study pooled 29 items on the Active Aging Scale out of a possible 36. Two items were removed in the first process as not relevant to the context and two items that were not maintained inter-item covariance that is less than the value of 0.30 were removed. In the confirmatory factor analysis, three items with values below 0.40 in Varimax with Kaiser Normalization Rotation. Item loads ranged from 46 to 0.90, and were found to explain 65.42% of the total variance. Confirmatory factor analysis of the AAS shows Chi-squared (X2/df = 2.24) as the degree of freedom is acceptable when <3.00 in model fit indices. The root mean square error of approximation (RMSEA) is 0.042, the goodness of fit index (GFI) is 0.92, the adjusted goodness of fit index (AGFI) is 0.94, and the comparative fit index (CFI) values are 0.92 and 0.96, respectively, showing the good fit indices of the model. The test and retest reliability of the scale was significant (p=<0.05), and the Cronbach alpha of the scale is 0.92, which is reliable.

Full text

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The translation process of the Culturally Sensitive Active
Aging Scale for Community-Dwelling Older Adults in Pakistan
Rashida Bibi
Institution of Nursing and health Sciences, Zhengzhou University
Roheeda Amanullah Khan
Government Nursinf College, Hayatabbad Medical Complex, Pakistan
Akhter Zeb
Ismail Nursing College Sawat, Pakistan
Zhang Yan (  zhangyan2010@zzu.edu.cn )
Institution of Nursing and health Sciences, Zhengzhou University
Nasir Anwar
National College of Nursing, Sawat, Khyber Pakhtunkhwa19110, Pakistan
Nasar Mian
Odhyana College of Nursing, Sawat, Pakistan
Research Article
Keywords: psychometric, translation, Active Aging, scale, Urdu, elders, Pakistan
Posted Date: April 21st, 2023
DOI: https://doi.org/10.21203/rs.3.rs-2797257/v1
License:   This work is licensed under a Creative Commons Attribution 4.0 International License.  Read Full License

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Abstract
Background: Active aging is dene as older adults remaining active, connected, and contributing to society. To assess
active aging in Pakistani elders, there is a scarcity of research tools to assess Active Aging levels in community-based older
adults in Pakistan. Therefore, the aim of this study was to translate and validate the original English version of the Active
Aging Scale into an Urdu version to measure active aging in community-based older adults in Pakistan.
Methods: We followed the guidelines of the International Society of Pharmacy Economic and Outcome Research (ISPOR) to
translate the scale. The rst phase consists of translation processes; the second phase is all about the validity and
reliability of the scale. Construct validity, concurrent validity, and reliability were established for a 160-person sample of
community-based older adults. The nding of test-retest reliability was performed after a two-week interval on the
remaining 30% of the sample. For concurrent validity, the Successful Aging Scale (SAS) Urdu version was used as the gold
standard and applied at the same time on the same sample. Data were analyzed in SPPSS version 23, and AMOS version
23.
Results: Our study pooled 29 items on the Active Aging Scale out of a possible 36. Two items were removed in the rst
process as not relevant to the context and two items that were not maintained inter-item covariance that is less than the
value of 0.30 were removed. In the conrmatory factor analysis, three items with values below 0.40 in Varimax with Kaiser
Normalization Rotation. Item loads ranged from 46 to 0.90, and were found to explain 65.42% of the total variance.
Conrmatory factor analysis of the AAS shows Chi-squared (X2/df = 2.24) as the degree of freedom is acceptable when
<3.00 in model t indices. The root mean square error of approximation (RMSEA) is 0.042, the goodness of t index (GFI) is
0.92, the adjusted goodness of t index (AGFI) is 0.94, and the comparative t index (CFI) values are 0.92 and 0.96,
respectively, showing the good t indices of the model. The test and retest reliability of the scale was signicant (p=<0.05),
and the Cronbach alpha of the scale is 0.92, which is reliable.
Introduction
Life expectancy is increasing in Pakistan. According to the population census, there are approximately more than 25 million
senior citizens in Pakistan, making up to 6 to 10 percent of the population[1], [2], expected 24% increase in 2050. It is
evident from the recent research[3], [4] that community-based older adults are the most marginalized and least focused
population in the Pakistani health care system [5]. Although this population is a higher-risk group due to physical and
mental declines, The prevalence of chronic diseases is high in the older population, which can cause changes in social
participation and self-care[6], productivity, and poor health management[7], and their sense of self-identity, both of which
can lead to inactive aging [8], and poor quality of life[9]. On the other hand, studies supported the idea that older adults are
the main stream of the society's development and for nancial stability[10]. The strategies of active aging enable people to
actively engage in the work market, society, and family activities and live healthy, independent, and secure lives. The reason
is that setting in place the conditions to enable people to live an active and healthy life is the mediator for the economic
stability of the health care system in aging societies and for improving the quality of life for the elderly population. This
strategy also strengthens social cohesion between generations[11]. Therefore, research instruments are needed to represent
multiple concepts and components about general functioning and promote of active aging in older adults in Pakistan [12].
Previous studies mentioned that a scale should adhere to conventional standards of reliability and validity[13], To be useful
in a community setting, measures must also be simple and easy to adopt for older adults with less education [9]. In the
past, there was stigma associated with older adults, who were seen as a burden on society or a useless part of it. In recent
decades, the concept of healthy aging or active aging has become a focused research topic in the eld of geriatrics[14].
There was more focus on the negative consequences of aging than on their usefulness. Therefore, in this regard, research
on active aging considers the positive aspects of aging in society[15].

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Over the past two decades, several conceptual denitions, models, and contents of active aging, successful aging, healthy
aging, active aging, and its measures have widely appeared in the literature[8][14], [16].which were used to assess levels of
active aging or successful aging under the different theoretical underpinnings. However, the most comprehensive and
widely recognized denition comes from the WHO policy framework and life course program: Active aging is the process of
augmenting health opportunities, societal participation, and safety security in order to improve perceived well-being and
quality of life as people get older[16], [17]. As an European study discussed in detail [18] Active aging has diverse aspects,
including employment, social participation, empowerment, life style, nancial security, etc., that should be noted and
assessed to promote healthy aging. Moreover, the WHO policy framework also for active aging emphasizes the need to
promote and assess older adults' self-care, societal contribution, nancial security, engagement with life, spiritual wisdom,
and healthy lifestyle[11]. Therefore, researchers and policymakers' intent is to promote active aging interventions and
strategies to promote healthy aging communities across the world. The scales of active aging, healthy aging, and
successful aging inventories went through different editing and adapting processes in the previous studies[4], [17], [19], [20].
The measures that work well in general populations may not work well for older people [6]. To apply in a community setting
a scale should be easy, and brief to read and use in a short time to retain their attention and interest[21]. Meredith Troutman,
a professor at the University of North Carolina, developed a successful aging index (SAI), which consisted of four domains
and 20 items[22]. In addition to that, Kattika Thanakwang developed the Active Aging Scale (AAI), which consisted of seven
factors and 36 items for elders in Thailand[8], Ziadi.et al developed four domains of active aging scale, containing
employment opportunities, social participation, independent and healthy living, and active aging capacity[16]. Eun Lee
developed the Active Aging Inventory (AAI) in the United States of America, which included four domains of WHO active
aging strategies[4]. These all-inclusive scales are valid and reliable instruments in cross-cultural settings. They included
various WHO-focused dimensions of active aging and were signicantly correlated with several related criterion measures,
including the healthy aging scale, the successful life scale, and the empowerment scale[17], [23]. Previous studies
supported the requirement that a culturally sensitive instrument require the collection of unbiased data, as different scales
adopted from others may not fulll the criteria of cross-cultural sensitivity of a scale. Multiple scales are currently
available[8], [24] [8], [14] that assessed the active aging level in the elder population in other countries with different
cultures. Although, Anwar translated a English version successful aging scale into Urdu, consisted of three factors, 14 items
in which self-reliance, healthy life style and adoptive coping[25],is seen similar to the items of Active Aging Scale 36 There
was an urgent need to develop a culturally sensitive study instrument in Urdu to assess the active aging status of elders in
Pakistan. Unfortunately, there is a dearth in the availability of a scale in the local language to assess elders' active aging
status in Pakistan. After a literature review, we selected a scale developed by Kattika Thanakwang and colleagues[8].The
author focused on all the WHO-proposed dimensions of active aging. The scale consisted of 36 items and a ve-point
rating scale from strongly agreeing (5 points) to strongly disagreeing (1 point). The AAI-Thai establishes good validity and
reliability (Cronbach’s alpha of 0.92). This scale went through a translation process in different languages to make it
culturally appropriate. It was necessary to conrm the construct validity of the translated instruments in the current data
because these instruments are utilized in Western and in some other Asian civilizations with diverse populations and
distinct cultures[14], [19]. Research has indicated that the common approach to checking validity is content validity and
construct validity, which tell us regarding the adequacy of the construct to be measured[19].It explains the relevancy and
comprehensibility of the mentioned items for the construct, context, and population of interest, so it is highly required to be
examined[14]. It is evident from the previous studies that the adaptation process of a research scale does not have any
universal agreement [8], [9]. Pakistan is a country in which the features of the population are indigenous, so this translated
version of the scale will be convenient and can be easily administered. Therefore, the aim of this study was to develop a
cross-culturally relevant, valid, and reliable study tool to assess active aging among community-based Pakistani older
adults. This scale will measure the multiple indicators of active aging that the WHO recommends assessing for active aging
in all countries. The Urdu version of the active aging scale will be a convenient scale to use in future research on the
geriatric population.
Materials And Method

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Phase.1
Procedure
Instrument:An Active Aging scale was chosen to translate into local language which is “Active Aging Scale-Thai” developed
by Thannak wang and others in Thailand[8]. This scale consisted of 36 items in ve Likert scale from strongly agree=5
points to strongly disagree=1 point. The scale obtained Cronbach Alfa 0.96.
We followed the recommendations made in the International Society of Pharmacy Economic and Outcome Research
(ISPOR) report for translation and cultural adaptation[25],and the consensus-based standard for the selection of the
COSMIN) checklist [26] was followed throughout the translation process of the scale (see gure1.).
Step1. Permission taken from the author:After a literature review regarding the components of active aging, we approached
the primary developer of the scale through email.
Step.2 Forward, transition: The scale were given to two independent bilingual translators to translate into Urdu language.
During translation process, there was no replacement or deletion of any items and maximum similarity of the source and
target language was maintained.
Step.3 Expert comments to select the items:Two bilingual experts from Peshawar University and one PhD scholar from the
nursing department of Khyber Medical College were approached to select the best version for further process.
Step.4 backward translation: The translated version retranslated into the original language by other bilingual experts who
were not familiar with the primary translators.
Step.5 Feedback study: Focus group of ve experts (2 PhD scholars in nursing and faculty members of Khyber Medical
University, one community health nurse, lecturer in government nursing college Peshawar, and one language expert
professor Peshawar University and one general public gure) retired principal from government were arranged to nalized
the nal draft on 22 March 2022. The committee evaluated each item, and they looked for agreement between the original
scale and the translated English form. Assigning 1 to 4 scores for clarity and relevancy checked content validity index and
scale validity. Only two items were not culturally sensitive were omitted in this stage. To communicate their greater insight,
some of the words were placed within parenthesis[19].The average of I-CVIs is 0.93 for clarity and 0.90 for relevancy. If the
I-CVI is higher than 83%, the item will be appropriate. (seeTable.1)
Step.6 Face validity: We followed a one-to-one approach to check the structure and its representativeness as a whole.
Step.7 Piolet testing:We conducted a piolet study on 30 participants to check the 34 items scale's internal consistency and
the ability of the questionnaire to proceed further. The participants in the piolet study were not included in the main study.
Table.1 CVI, SCVI of Clarity and Relevancy of translated version of Active aging scale

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Comp Items TA ICVI UA SCVI TA ICVI UA 
Comp=1 Scale Item 1  1 1 0.8889 5 0.833 0 0.967
Scale Item 2 5 1 1 6 1 1
Scale Item 3 2 0.5 0 6 1 1
Scale Item 4 3 0.833333333 0 6 1 1
Scale Item 5 5 1 1 6 1 1
Scale item 6 5 1 1 6 1 1
Scale item 7 2 0.25 0 5 1 1
Scale item 8 5 1 1 6 1 1
Comp=2 Scale Item 9 5 1 1 0.9222 6 1 1 0.972
Scale Item 10 5 1 1 5 0.833 0
Scale Item 11 5 0.833333333 1 6 1 1
Scale Item 12 4 1 1 6 1 1
Scale Item 13 6 1 1 6 1 1
Scale Item 14 3 0.50 0 6 1 1
Scale Item 15 6 1 1 6 1 1
Scale Item 16 5 1 1 6 1 1
Component .3 Scale Item 17 4 0.666666667 1 O.93 6 1 1 0.96
Scale Item 18 6 1 1 5 0.833 0
Scale Item 19 6 1 1 6 1 1
Scale Item 20 6 1 1 5 1 0
Scale Item 21 6 1 1 6 1 1
Component.4 Scale Item 22 3 0.5 0 0.875 6 1 1 1
Scale Item 23 6 1 1 6 1 1
Scale Item 24 5 1 1 6 1 1
Component.5 Scale Item 26 5 0.833333333 1 0.9667 6 1 1 0.967
Scale Item 27 6 1 1 5 0.833 0
Scale Item 29 6 1 1 6 1 1
Scale Item 30 6 1  6 1 1
Comp 6 Scale Item 31 6 1 1 0.95 6 1 1 0.958
Scale Item 32 6 1 1 6 1 1
Scale Item 33 6 1 1 5 0.833 0
Comp7 Scale Item 35 6 1 1 1 6 1 1 1
Scale Item 36 5 1 1 6 1 1 

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
Total ICVI
 0.933322 ICVI 0.96
Total SCVI 0.949074 Total SCVI 0.97
SCVI AVE 0.91666 SCVI AVE 0.8
Step.9 Reliability of the piolet study data: Three criteria were used in the process of deciding which items to retain: 1) a
minimum inter-item correlation of 0.20 and a maximum of 0.70, 2) a minimum corrected item–total correlation coecient
of 0.30, and 3) a minimum Cronbach’s reliability of 0.70[8]. After that, we calculated Cronbach’s Alfa. Results show that the
sum of item variance (S2Y) is 55.5324; while the variance of the total scores (S2) is 243.0916 on this translated scale. The
Cronbach's alpha of the piolet study by applying the formula: 36/36-1*55.5324/243.0916-1 = 0.80. We know that
Cronbach's alpha > 0.80 indicates that the scale is more reliable to apply in the study[17].
Ethical Consideration:Before collection of data, permission taken from the parent institution, that is, Institution of Ethical
Review Board, Zhengzhou University, Henan, China(ZZUIRB #202254), and the District Health Department Oce (DHO
#14207). We were taken verbal and written concerns from the participants, maintained anonymity and privacy, and ensured
them that they have the right to withdraw from the study in any time.
Phase.2
Reliability of translated version of Active aging scale
Sample: Data was collected after a survey was conducted among community-based older adults to determine whether AAS-
Pak could address the level of their active aging. This study included 160 older adults aged >60 years, with ages ranging
from 60 to 85 years. A purposeful, convenient sampling method was followed to collect data (N = 160). The participants
were living in Peshawar, Timergara, Dir Lower, Khyber Pakhtunkhwa, Pakistan, representing a diverse cultural background.
The following inclusion and exclusion criteria were followed: 1) Participants agreed to participate in the study. 2); not
having a sensory or cognitive impairment. We excluded those who were considered to have diculties in understanding
language. We excluded all those who were hospitalized at the time of data collection, had disabilities due to any reason, or
were mentally ill. Data was collected in 7 June 2022 to 21 June 2022. Regarding recruitment of the participants, we adopted
the MC Challun sample selection criteria of at least 5-10 respondents of each item is required for statistical analysis of
reliability and validity of a data [27]. The gender distribution was almost equal male 54% and female 46%, the interesting
thing about this study is that nearly half of the participants, or 43%, were nancially dependent on other family members.
The education level among this group was very low, as 56% could only understand Urdu and had no formal schooling; more
than that, only 6% were at the graduate level. (See Table.2)
Table.2Demographic distribution of the study participants N=160

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Variables Total No Percent (%)
Age 60 to 65 yrs. 34 21%
66 to 70 yrs. 92 57%
71 to 75 yrs. 22 13%
>76 yrs. 2 7%
Marital status Married 135 84%
Widow 25 15%
Gender male 85 53%
female 75 46%
Living status alone 15 10%
with other family 145 90%
Health status One chronic disease 92 58%
>1 chronic diseases 38 24%
No any chronic diseases 29 18%
Source of Income Pension 45 28%
Other 58 36%
Dependent 57 35%
Illiterate 93 58%
Primary 45 28%
Education status secondary 16 10%
high secondary 5 3%
Graduation 2 1%
In the table.2
,
the majority of the participants' ages ranged from 66 to 70 years in this study. The nancial status of the
participants shows that a high percentage of elders are dependent on their family members. Majority of the elders reported
at least one chronic disease such as hypertension, diabetic mellitus, asthma and arthritis. Financial dependency has a
direct relationship with the lack of empowerment, decision-making ability, and autonomy of elders, which may cause low
quality of life.

Procedure
For the general scale and its subscales, we measured reliability using Cronbach's alpha, and Pearson correlation coecient
values. For a new tool, a Cronbach's alpha value of 0.70 and higher suggests adequate internal consistency.
Ceiling and oor effect of the data: The proportion of respondents scoring the highest (ceiling) or lowest (oor) possible
score across a given domain to assess the proportion of subjects scoring the best (maximum) or worst (minimum) score of
each item. We considered the +3 or -3 formula that is 30% of the higher and lower level of the data to examine the
discrimination. Items below 15% of the threshold for a missing item response were omitted. Items with the mean + with

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standard deviation (SD) exceeding the range and with maximum and minimum scores exceeding 15% were deleted by
applying the ceiling and oor effects methods used in the previous studies[28].Two items were deleted with 30% lower
scores.
Findings
The item-total correlation, inter item correlation, and inter subscale correlation of the 30-item were examined. Correlation
coecients ranged from 0.1 to 0.81, the item-item correlation coecients ranged from 0.24 to 0.72, and the inter-subscale
correlations ranged from 0.383 to 0.881. Item-total relationships for one of the items (items28) were < 0.30; we decided to
not delete it, as deletion might not improve the value of Cronbach alpha. The reliability for the entire scale was 0.88, which
is regarded as excellent, and the alpha coecients for the seven subscales varied from 0.86 to 0.90. (See Table.3)
Table.3The correlation coecient of inter subscale, subscale and total scale and Alpha coecient of the nal draft of 29
items AAS-Pak
Total scale components SR LIS HLT SW ES SFT SC Cronbach
Alpha
Being self-reliance 1       0.87
Learning and I integrated into
society .490** 10.86
Healthy life style .528** .478** 10.88
Developing spiritual wisdom .676** .409** .868** 10.89
Economic security .387** .405** .356** .388** 10.90
Strengthen   family ties .676** .353** .418** .307** .670** 10.90
Contribution to society .393** .411** .478** .486** .384** .405** 1 0.88
Total scale correlation values .768** .845** .725** .709** .400** .006 .550** 1
Abbreviations: SR=Self-reliance, LIS=learning and integrate into society, HLT=healthy life style, SW=spiritual wisdom,
ES=economic security, SFT=strengthen family ties, SC=social contribution.
In the above table the overall Cronbach Alpha is 0.88, and the 7 subscales ranged from 0.862 to 0.90, indicating good
internal consistency; Pearson correlation among each variable is signicant with
(P=0.001), and (P=<0.05
). P.value of SR,IS,
HLT,SFT=(P.<0.01), ES,SC, SW=(P=<0.05).
According to Gen, if the item-total score correlation coecients are positive that is >0.30, it means that the scale's items
distinguish well by the people , provide examples of comparable behaviors, and have a high degree of internal
consistency[29].
Construct Validity
Exploratory factor analysis, and conrmatory factor analysis was performed, established item weights (0.40) in principle
component analysis to obtain a maximal reliable scale. KMO and the Bartlett test of sphericity was applied to check the
sample adequacy; factor matrices of loading for conrmatory factor analysis using methods of maximum likelihood factor
analysis (MLFA) and principal component analysis (PCA) in the exploratory factor analysis model.

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Active Aging scale.To check the structure validity of the instrument, different t indices were estimated to evaluate the
overall t model for the measures through structural equation modelling.Varimax with Kaiser Normalization rotation using
least squares >o.4 an eigenvalue value >1 value in factor loading [30]. All items with values less than 0.4 in Varimax
rotation were deleted, and the remaining items were reloaded for refactor analysis [43].
Procedure
Sample:A convenient sampling method was used to collect data from community based 160 elders age >60 years in
Khyber Pakhtunkhwa province and met the inclusion criteria. Permission was taken from the participants before data
collection.
Findings
Data adequacy: KMO and the Bartlett test of Sphericity ratio is > 0.5 for the data set to be considered suitable for further
factor analysis[19]. The research revealed that the KMO coecient was.0.701. (Table.4).
Table.4KMO and Bartlett's Test
Kaiser-Meyer-Olkin Measure of Sampling Adequacy.
.871
Bartlett's Test of Sphericity Approx. Chi-Square
1999.463
df 135
Sig. .000

Findings Regarding Validity Analysis Results of AAS-Pak
Exploratory Factor analysis: The ndings showed that seven factors explained 65.4% of the total variance. All factor
loadings had statistical signicance and were higher than 0.40 in the Varimax rotation. Lastly, 29 elements were kept, and
seven factors with eigenvalues greater than 1 were formed. The eigenvalues ranged from 8.3 to 11.65, and the total
variance was explained by all components in 65.48% of the cases. The factor loadings were statistically signicant
(P=0.001), and the communality values ranged from 0.42 to 0.85, indicating that a large amount of the item variance was
explained by the extracted components, organized theoretically, and had their best-dened structure (see Table 5).
The component matrix in the factor analysis supported the seven components, their corresponding eigenvalues. Two items
(17 and 33) were deleted from the communality score because they were lower than 0.40, the cross-loadings indicated
relatively high loadings on more than one factor, and the item did not contribute to factor interpretability. The 29 retained
items could all be meaningfully explained by only one of the seven factors and had loading values greater than 0.40 on all
the retained items (see Table 5).
Table.5Factor
loading in principle factor analysis

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S# Items Extraction S# Items Extraction
1 SR1 0.78 15 HL16 0.6
2 SR2 0.79 16 HL17 0.7
3 SR3 0.71 17 HL18 0.8
4 SR4 0.69 18 HL19 0.9
5 SR5 0.73 19 HL20 0.8
6 ISL6 0.5 20 CS21 0.7
7 ISL7 0.7 21 SC22 0.7
8 ISL8 0.67 22 ES23 0.9
9 ISL9 0.67 23 ES24 0.7
10 ISL10 0.46 24 ES25 0.8
11 ISL11 0.82 25 SW26 0.7
12 ISL12 0.64 26 SW27    0.7
13 ISL13 0.48 27 SW28 0.8
14 HL14 0.62 28 SFT29 0.7
15 HL15 0.68 29 SFT30 0.7

In the Table.5 factor loading of 29 items in Active Aging-PAK, retained values range from 0.46 to 0.92 showing one
dimension as >0.40 were accepted to be retained in principle factor analysis with Varimax rotations. According to
Cigdem[19],factor load values are expected to be >.40 or higher. According to the factor load values, it is seen that the scale
consists of a diverse dimension and 29 items. The item values show that we need to keep 29 items out of 32. Note:
Abbreviations are explained in table 3 for reference.
Discriminatory validity: Regarding discriminant validity, all seven AAS-Pak subscale scores and the total score were
unrelated, indicating that the AAS-Pak is not confounded by the tendency of participants to respond in a self-interest as a
desired manner.
Convergent Validity
:
The total variance explained seven dimensions in which the variances among variables greater than
critical value of 95% condence (0.5). According to Yuksel and colleagues [19], factor load levels should be at least 0.40.
The scale appears to have 29 items with seven dimensions based on the factor load values>0.40, and the variance among
factors are not <0.30. The AAS-Pak was explained total variance amounts, which are listed in Table 6. AAS-Pak observed to
account for 65.2% of the overall variance.
Table.6

Total variance explained in the exploratory factor analysis of the seven components of Active aging-Pak

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Total Variance Explained among seven variables of AAS-Pak 29
Component Initial Eigenvalues Extraction Sums of Squared
Loadings Rotation Sums of Squared
Loadings
Total % of
Variance Cumulative
%Total % of
Variance Cumulative
%Total % of
Variance Cumulative
%
SR1 4.839 22.797 22.797 6.839 22.797 22.797 5.082 16.940 16.940
IS2 3.594 11.981 34.778 3.594 11.981 34.778 4.643 15.475 32.415
HL3 3.123 10.411 45.189 3.123 10.411 45.189 3.152 10.506 42.921
SW4 1.678 5.595 50.783 1.678 5.595 50.783 2.074 6.913 49.834
SF5 1.616 5.386 56.169 1.616 5.386 56.169 1.607 5.357 55.192
SC6 1.413 4.711 60.880 1.413 4.711 60.880 1.555 5.184 60.375
ES7 1.381 4.602 65.482 1.381 4.602 65.482 1.532 5.107 65.482
Extraction Method: Principal Component Analysis.
Table. 6 The seven components of active aging: 1, being self-reliant; 2, actively engaged with society; 3, developing spiritual
wisdom; 4, building up nancial security; 5, maintaining a healthy lifestyle; 6, societal contribution; 7, strengthening family
ties to ensure care in later life.
Conrmatory Factors Analysis: Conrmatory CFA was employed with Amos version 23 to establish the construct validity of
the instrument.
We examined the magnitude of the loadings on each variable one by one and assessed the extent of variance accounted
for. In the path analysis, components' relationships with assigned items in the model were assessed. Furthermore, in the
verication of measurement error, we calculated the Chi-Square (χ²), comparative t index (CFI) round-square standard error
(RMSEA), goodness of t index (GFI), the adjusted goodness of t index (AGFI), and the relative t index (RFI) in the model
t analysis.
Structured validity of the scale:
For the structural validity of instruments, several t indices were estimated to see the overall
t model for the measures through structural equation modelling.

The seven factors solution matches well according to the
CFA results for the scale's 29-item structure. In the conrmatory factor analysis, Chi square X2/ df is 418.18(28), (df.2.2) in
the standardized model which is <3 indicated good t of the model. The value of RMSEA (0.12), GFI0.64, CFI (.68) were not
signicant in default model, which were managed through error variance in standardized model. The RMSEA is 0.042 which
is <0.80 indicating acceptable to model t, the goodness of t index(GFI) value is 0.92 which is >0.90 is acceptable,
adjusted goodness of t index(AGFI) value is 0.94 showing good t of the model, comparative t index(CFI) values are 0.92
to 0.96 respectively. CFI value is 0.92 as>0.80 is acceptable.Figure.2, gure3, and table.7 show model t structure of the
scale.
Table.7Model t in conrmatory factor analysis of 29 items of AA-Pak
Active Aging
Scale Model X2(df) NFI IFI TLI CFI RMSEA
(df) ∇χ2-
(Δχ2df)
Unstandardized
Model 493.
23(52) .68 0.72 64.56 .68. .12 
Standardized
model  0.88 0.89 0.92(>0.90) 0.91(>0.80) 0.64
(<0.80) 418.18(28)

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Abbreviations: IFI= Incremental Fit Index NFI=, Normed Fit Index, TLI= Tucker-Lewis Index, CFI= Comparative Fit Index,
RMSE= Root Mean Square Error of Approximation, and χ ²= Chi-Square correlation coecient.
1.Model.1 is default model without adding error variance
2. Mmodel.2 is standardized after adding error variance.
Note1. Chi- square test: The value is a statistical test of goodness of t of a factor model, prepare observe covariance
matrix with a proposed covariance matrix.
Note2. Root Mean Squared Error of Approximation (RMSEA): RMSEA is a measurement of the estimated disagreement
between the population and the population in model-implied covariance matrices per degree of freedom.
Note3. Tucker Lewis Index (TLI): TLI is based on the concept of contrasting the proposed factor model to a model in which
absolutely no assumptions are made regarding the interrelationships between any of the elements.
Note4. Comparative Fit Index (CFI): The incremental relative t index, or CFI, evaluates how much better a researcher's
model ts than a baseline model
Model with correlated errors:
Error of covariance in factor analysis research is signicant to hold items without
deletion[30],in order to achieve a satisfactory t, we reanalyzed the data set while leaving error covariances in the
model.

The estimations were high in three factors between items and factors, which are high in CFA. The active aging
scale’s seven -factor structure and composite scores have both been studied. Model visual representation showing factor
loading and model t. Figures 2 and 3 depicted CFA model t structures of the scale.
Criterion Validity:The Active Aging Scale was not translated into the Pakistani national language (Urdu), so there was a
need to establish its validity criteria as well. According to Baoteng. et al, analyze the relationship between scale scores and
the "gold standard" of scale measurement; a stronger signicant relationship as measured by Pearson product-moment
correlation shows that concurrent validity is supported[30]. Therefore, the Successful Aging Scale, which has already been
validated by Anwar and colleagues in Islamabad, was applied to the elders and thought to be similar to the AAS-Pak, and its
results were examined[25] on the same Likert scale. Signicant positive relationship between AAS-Pak and SAS with the
SR=0.85**, LIS=75**, HLT=81**, and the overall Successful aging scale (SAS) (r=0.86**, P= <0.001).
Test retest reliability:To assess the stability of the last version of the AAS-Pak with 29 items, we re-approached 35 elders
who live in the Peshawar district, who showed a mean score of 98.2 at time one, and a mean score of 95.60 at time two.
The two groups of scores' Pearson correlation coecient, which measures the stability of the scale with Cronbach Alpha
values of 0.92 and 0.88, respectively. Additionally, the seven subscales' correlations between time one and time two varied
from 0.77 to 0.90. (See Table 8). The 29-item AAS-Pak is stable in terms of test-retest reliability, according to the
ndings.Table.4. Test retest stability check of AAS-Pak with sub sample
Table.8 Test retest reliability of the AAS-Pak 29 N=35

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First time data Data after 2 weeks r=
 Mean Std. Deviation  Mean Std. Deviation 
SR 16.6188 4.36808 SR 22.319 5.017 0.84
LIS 27.1688 6.83335 IS 31.625 9.612 0.78
HLT 23.0125 4.79122 HL 20.025 5.049 0.84
SW 10.1125 2.92675 SWL 15.425 2.762 0.77
ES 10.5500 2.16838 ES 9.7813 1.922 0.81
SFT 7.4000 2.22677 FS 12.45 1.722 0.85
SC 6.6375 1.51507 SC 6.5563 1.999 0.79
TOTAL 98.2125 11.95978 TOTAL 95.60.113 10.74 0.8
Cronbach Alpha=0.92   Cronbach Alpha=0.88 

In the table8, we calculate how repeatable the participant's performance is, i.e., how stable their scores are over time is
showing consistency beteeen two time data collected from the participants with Cronback Alpha 0.92, and 0.88 in the
second data.
Discussion/ Conclusion
The research goal was to translate, validate, and investigate the active aging scales with 36 items. The translation process
in this study was split into two sections. The section 1 addressed Active Aging Scale translation process and examined the
temporal validity and reliability of the scale for further process [29]. Cronbach Alpha 0.80, CVI, and SCVI >0.90 of the data
collected from (N=30) indicates the stability, and acceptability of the scale for further analysis. In this stage, two items were
not supported in item variance value<0.30 were emitted. The items were highly similar with other item such as I stretch my
body three time daily and I exercise three time in a day. The 36-item of the original scale was reduced to 34 items in the rst
expert committee decision. In the temporal validity and internal consistency analysis, 30 items were secured in the scale for
further analysis. According to Baoteng, the probability of the item reduction is expected in the rst stage of study scale
development and translation process[30].
In the part two, internal consistency of the Urdu-version scale consisted of 30 items were measured. Data were collected
from (N=160) men and women made up an equal amount of the sample. Data obtained from 160 people were analyzed for
internal consistency, which shows Cronbach Alpha 0.92 as excellent to implement.
Factor analysis(exploratory, and conrmatory factor analysis) sustained the seven components with 29 items with seven
factors self-reliance, learning and integrate into society, healthy life style, spiritual wisdom, social contribution, nancial
security, and strengthen family ties which reveal that the scale has sustained the structure of the original scale except one
component that is social learning style. In the literature different concepts were generated in terms of social contribution,
healthy life style, independent, mental wellbeing; it is seen that participation in social participation, autonomy. healthy life
style, and contribution to the society were measured as active aging components[31]. In this study, it is seen that items
pooling was created at a point covering the topics available in the original scale and many others in different context[16].
Psychometric analysis in part 2 involved the establishment of construct validity using conrmatory factor analysis on a
group of older adults (N = 160). When we look at the descriptive information of the elderly people, the proportion of
uneducated participants is quite high, at 58% of the total, but the participants speak and understand the Urdu language. The

Page 14/19
age distribution of the participants is over 60 to 70 years old (62%). The fact that the majority of the elderly live in a joint
family system shows a strong family support system in Pakistan. The nancial dependency on other family members is
high, which is consistent with the previous study in Thailand [8], but not consistent with a European study in which elders
were not dependent on their children[16]. In our study, female participants had a higher dependency ratio on their children
than male participants, which is not surprising given that females were encouraged to stay at home and take sole
responsibility for domestic affairs and child care[2]. After examine the previous studies, it is seen that huge different in
terms of demographic values conducted for active aging[19], [22], [32].
In the factor analysis, 29 items were loaded clearly; ve items for self-reliance, eight items of learning and integrate into
society, seven items are for healthy behavior, three items for spiritual wisdom, two factors for economic security, two for
social contribution, and two were for strengthen family ties.
In the construct validity, the scale maintained its seven factors structure as it had been implemented in previous studies in
different languages [30] but the items loading of three factors were not similar to the original scale. This variance can be is
due to development of cultural sensitive scales in different countries with some variations in the components may
inuenced.
The seven factors are correlated with each other supporting the entire scale as valid and good t with signicant of
(P0.01),RMSEA value 0.42, (GFI) value is 0.92 which is >0.90 is acceptable in this model. According to Figure 2, the active
aging scale's factor loading spans from 0.42 to 0.90. This results showed that the translated instrument obtained 29 items
with seven factors evaluated in the current research was equally applicable and valid to Pakistani culture, as were applied in
the native caulture[8]. The items are vary in each factor as items were loaded are not very similar to the origional version.
Self-reliance consisting of ve items, three were eliminated due <3 scores in item variance focused on self-care, tasks
related to self and family care, performing various activities in the household. From the perspective of older adults, being
able to do what they wish is meaningful for their autonomy and implies that they can manage their lives on their own[22].
The collectivistic nature of Islam and cultural norms, the people are interconnected, and they held individuals accountable
for one another [31]. This notion is consistent with the valued concept of individualism among elderly Western people[13],
and Yorozuya’s study in Japan [24]. The concurrent validity of the scale were measured through 14 items in three
components of Successful Aging Scale in which most of the items in self-reliance and health aging were similar to AAS-
Pak. Therefore, this scale were hypothetically related to active aging scale, used as a gold standard in this study. Signicant
positive relationship between AAS-Pak and SAS with the SR=0.85**, LIS=0.75**, HLT=0.81**, and the overall Successful
aging scale (SAS) (r=0.86**, (P=<0.001). Surprisingly, our study results are consistent with the results of these studies
although carried out in other context such as Japan[24] used health questionnaire, Turkey, successful aging scale, and
Aging in place scale as a gold standard[19]. The reason can be elimination of few items due to not relevant in this context,
and the similarity can be supported by WHO “aging well frameworks” in which standardized active aging determinants were
highlighted to address with combine efforts such as independent as long as possible, participate in activities, productive
life, safety and security, social support.
The overall AAS-Pak score's Cronbach alpha internal consistency of seven variables were consistant as the average
Cronback Alpha value was 0.92 in this study. According to Zamanzadeh [28] a scale is considered to be extremely reliable if
its alpha coecient is 0.80 or higher. These results demonstrate that the AAS-Pak is an accurate instrument to assess the
level of active aging in community based elders in Pakistan. The 29 items were culturaly acceptable as these items were
consistent with the other studies with different cultural backgrounds [22]. According to Baoting the social believes,
emotions, and needs of elders may not be different from context to context [22], [30].
The test retest reliability of the scale is showing mean scores of 105 value at rst time with Cronbach Alpha 0.92 ,and a
mean score of 106.80 in the second time with Cronbach Alpha 0.88 shows that the validity and reliability of the scale is
stable. The scale is seen to be stable and valid in various context with some attrition and deletion of the items as per their
relevancy to the context[14], [22], [24].

Page 15/19
Limitations of the study: The scale is developed only in an adaptive manner and translated into the Urdu language, which
may not fulll other aspects of active aging. The participants were not highly educated, which might be create problem with
their understanding. Therefore, the reliability of the scale might be compromised. In future studies, adding new items
through in-depth exploration of elders' perceptions about active aging may be needed, and then comparing with an active
aging scale developed in another culture would be useful to explore which dimensions of the Active Aging Pack are unique
and which are universal.
Conclusion
The Active Aging Scale-Pak might be Pakistan's rst multidimensional active aging scale that is relevant, valid, and
culturally contextualized. The 29-item Active Aging-Pak has been shown to have acceptable validity and reliability and an
acceptable degree of model t for determining the degree of active aging in older adults living in Pakistan, indicating that it
may be applied in both community and clinical practice settings.
Declarations
Institutional review and consent to participate: The study followed all aspects of the Helsinki Declaration. Ethical approval
was obtained from the Zhengzhou University Institute of Ethical Review Board (ZZUIERB #202254), and District Health
Department Oce (DHO #14207), and informed consent was obtained from all subjects involved in the study. Study
participants were briefed and debriefed about the study purpose, the use of data, and their rights to withdraw from the
study.
Consent for Publication: All authors have read and agreed to the published this version of the manuscript
Data Availability Statement: All the data is secured and available from the corresponding authors. The corresponding
authors will provide all the data on the demand of the journal
Competing Interest: We declare that we have no competing interest
Funding: This research received no external funding
Author Contributions: Conceptual work, literature review, and writing manuscript; Rashida Bibi and Roheeda Ammanullah
Khan, results, review, and discussion; Akhter Zeb and Zhang Yan, data collection, data analysis; Nasir Anwar, Nasar Mian
Acknowledgment: We would like to acknowledge the works and contributions of several researchers of tool development,
and its validation particularly, Yorozoya, Zhang, and Thanakwang for their contribution. We would also like to acknowledge
the nursing department of Zhengzhou University for miscellaneous support. We extend our gratitude to the participants and
scholars, language experts who taken part in this study process.
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Figures
Figure 1
translation process of the English version active aging scale

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Figure 2
Unstanderized regression rate in item loading in factor analysis model in defualt model
Note: Aabbreviations; SR=self reliance, IS=integrate into society, HL=healthy life, WS=spritual wisdom, SF=stregthen family
ties, SC=social contribution, ES=economic security

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Figure 3
Standerized regression rate in item loading in factor analysis model
Note: In the Figure3, conrmed that the dimensionality of the item variance was signicant in EFA as the standardized
regression rates show values above 0.40 in the regression equilibria with standard errors. The error variance show that there
is highly variability among factors and it indicated that the seven factors are impartially related to each other in the model.