Development and validation of the Lo’s Healthy and Happy Lifestyle Scale (LHHLS): The resilience in general population facing COVID-19 in Taiwan

Abstract

Background:

This article explores the effectiveness of development of the Lo’s Healthy and Happy Lifestyle Scale (LHHLS), which is an evaluative tool that monitors the resilience of the Taiwan population in times of such COVID-19 epidemic. Also, to verify factors of resilience, namely the reliability and validity of self-efficacy and positive thinking, and establishment of a prospective norm analysis.

Method:

The study mainly applied Explorative Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) to develop LHHLS and establish the reliability and validity of the tool’s structure, verify norm analysis and the reliability of data from each question using Cronbach’s alpha.

Results:

According to statistics, LHHLS has a good factorial effectiveness and relatively high reliability, with factor reliability analyses where Cronbach’s alpha lies between 0.83 to 0.94. The 14 questions in the LHHLS has a total variance of 67.04%. The tool includes two sub-assessments that are theoretically and statistically appropriate: mental health/self-efficacy and positive thinking.

Conclusion:

The tool LHHLS can be applied to populations affected by COVID-19. With participants’ self-awareness of mental health state and state of happy living, this tool is valid and reliable in assessing and evaluating the resilience of such participants against times of COVID-19. This study can become future use for epidemic prevention communities in monitoring residents’ healthy living and changes in their resilience. Also, can become a reference standard for interventions to reduce the impacts populations’ happy and healthy living, in times of biological disasters.

Keywords

COVID-19 Healthy and Happy Lifestyle Scale (LHHLS)resilience norm verification self-efficacy positive thinking

Background

Coronavirus Disease 2019 (COVID-19) began its spread in Wuhan City of China and has become a global threat. On 30th January 2020, COVID-19 was announced as a public health emergency that required global attention. On 11th March, World Health Organization (WHO) announced it as a global epidemic. Following the rapid escalation in number of confirmed cases and deaths, COVID-19 has affected globally 187 countries, with a global tally of 18,282,208 number of confirmed cases and a global death toll of 693,694 people (as of 5th August). These figures are bound to rise in the future and our global population, society, economy, environment have received heavy blows, with COVID-19 becoming a globalized biological disaster.

Taiwan placed past experiences dealing with SARS onto big data analysis, new technological skills, proactive overseas management, home quarantine, home isolation, community outbreak investigation and confirmed case detection and other related crisis managements, to successfully reduce the disaster’s impacts and the harmful spread of COVID-19 in Taiwan communities (Wang et al., 2020). Taiwan’s performance in epidemic prevention and resistance has surprised the world.

Global countries, in the face of COVID-19, have big-scaled prevalence of impact on human’s economy and lifestyle, caused loss of resources and lives, scarce and insufficient medical resources. A system to reduce such disastrous impacts on society will challenge the resilience of humans.

Geographically, Taiwan is in the subtropical region of Asia, where natural, manmade and biological disasters are common occurrences even in daily life. Such disasters include typhoons, earthquakes, floods, African swine fever, Enteroviruses, dengue fever, Severe Acute Respiratory Syndrome (SARS) and COVID-19. Compared to natural disasters, biological viral disasters can cause an epidemic and continue causing harm to human lives for weeks or even months.

Global outbreak of the contagious COVID-19 has caused widespread fear in many populations and panic buying of resources like daily necessities, including toilet paper and food, across Europe and America. Normal daily activities and commercialized activities have been heavily impacted even on the regional level and is likely to continue for a long time (Noji, 2001).

In Taiwan’s population study, approximately 9.2% of participants reported that they are increasingly pessimistic about how SARS has turned their lives in an atypical crisis (Peng et al., 2010). Thus, biological disasters challenged human lives, impacts humans’ psychological health, way of living and self-adaptability. This is something worth thinking about. Also, ponder about how to prevent and reduce disasters, continuously develop a healthy community, and how to practice healthy smart living in communities for the long-term.

In face of natural and manmade disasters all over the world, resilience within actions and medical science is increasingly emphasized (Charney, 2004; Masten, 2001). Resilience is defined as the ability to positively adapt in face of pressure or trauma (Luthar et al., 2000), and includes expected and related results of bodily health (Black & Ford-Gilboe, 2004; Humphreys, 2003; Monteith & Ford-Gilboe, 2002; Wagnild, 2008) and psychological health (Humphreys, 2003; Nygren et al., 2005; Rew et al., 2001). People who can withstand pressure are able to maintain a better function after experiencing it (Bonanno, 2004). Past decades of research have shown, human’s adaptability has multidimensional features and produces changes according to environment, time, age, gender, cultural background, lifestyle differences (Rutter, 1985; Seligman & Csikszentmihalyi, 2014; Werner & Smith, 1992). Earlier research has shown, restoration and hereditary (Caspi et al., 2003), biology (Charney, 2004; Morgan et al., 2002), psychology (Campbell-Sills et al., 2006; Tugade & Fredrickson, 2004), and environmental factors (Haskett et al., 2006; King et al., 1998). Richardson and his colleagues targeted this variable and made a hypothesis that begins with a starting point or ‘a stable state’ of biological psychology – mental stability (Jensen et al., 1990). Humans can allow their bodies, thoughts, and mental state to be adjusted according to living environments (Richardson, 2002). However, not all adaptive measures are effective, but instead, cause more destruct to the stability of biological psychological health. This novel and reintegrated journey of resilience can result in one of these four outcomes below:

(1) Increase opportunities of growth and strengthen adaptability of psychological traits

(2) Recover to the basic state of stability

(3) Affects the need for compensation for losses

(4) Poor adaptability due to inability to overcome pressure (Connor & Davidson, 2003).

As such, the ability of human’s recovering resilience post-disaster is seen as the ability to successfully respond and overcome pressure. In other words, verified results and data of a study, on the long-term monitoring of healthy, smart-living after disasters, have shown that there is a need to focus on, stimulate and emphasize human’s innate resilience against disasters. This aids in protection of individuals from chronic post-traumatic stress disorders (King et al., 1998; Waysman et al., 2001).

As such, this article further clarifies the foundation of resilience in biological – society psychological health. It is important to fully understand how humans respond to stress and trauma, which helps to prevent and intervene with a healthy, content lifestyle working model. This helps individuals recover from stressful events and stress-related diseases.

A study, conducted on the Hakka survivors from Taiwan’s 921 earthquake, reports that indicators, including reception, preparedness, self-reliance, spirituality, Hakka spirit, resources’ obtainability, societal support, the Internet, and other services, have a positive impact on post-disaster recovery (Jang & Wang, 2012). Indigenous groups have stated, in response to Typhoon Morakot in Taiwan, that they have many interactive strategies with the residents, in attempts to alleviate survivors’ sufferings, promote tribal culture and build a recoverable community. But these activities have been constantly ignored in post-disaster reconstruction initiatives (Fan, 2015). Another study on the gas explosions suggested an assistance plan for the resilience of societal psychological health.

Disaster Adaptive Cycle and risk events form a cause and effect relationship, and from the perspective of perceived risks, observe how societies resiliently adapt to environmental changes (Chiang et al., 2014). Also, this cycle emphasizes how to learn from adaptive abilities, strategize feasible systems and actively organize different types of responses 30. These build a friendly attitude toward societal adaptability and focuses on the whole culture (made up of individuals and society), where collaboration between traditional and scientific knowledge highlights the importance of magnified risks in society (Chiang et al., 2014) (Halfacree, 2006).

Many evaluative scales about resilience (Wagnild & Young, 1993), include various dimensions of it, including tenacity (Hull et al., 1987; Kobasa, 1979) and feelings of pressure (Cohen et al., 1983). However, these contingency measures lack generalizability (Carlson, 2001; Mosack, 2002) and have not been verified in Taiwan.

Thus, this study seeks to develop an evaluative tool that is convenient and contains a thoroughly verified resilience scale. Although other different scales have been developed, they have yet to receive widespread discussion and acceptance, and not one of these scales have been identified as a priority.

This research team considered the importance of reconstructing lifestyles in disaster and the impacts of various factors like encouraging psychological health.

As such, the research team have developed the Lo’s Healthy and Happy Lifestyle Scale (LHHLS) after going through reconstruction works in Typhoon Morakot and Kaohsiung’s gas explosion. The LHHLS serves as an evaluative tool about the impacts of disasters on individuals and societies, also to monitor the post-disaster recovery of residents. This serves as a reference to understand recovery of disaster communities through validation of indicators of healthy and happy living from the scale (Lo & Shieh, 2019). This tool understands from the perspective of individuals’ self-awareness, and contents are focused on a short evaluation of a healthy and happy lifestyle. This can be built upon healthy and happy living, and adaptability scale of Taiwanese population in face of COVID-19, with the norm of each question, reliability and validity of the scale.

Methodology

Data and study population

Participants are gathered between 8th April 2020 to 18th April 2020 through a survey on Google Forms, which was distributed in Taiwan towards the general public. A total of 1,714 individuals responded to this online survey, making up the pool of research participants, of which were 564 males, 1,138 females and five transgenders.

Research ethics statement

This research has obtained approval from the research ethics committee in National Cheng Kung University (Certificate for standard ethics: NCKU HREC-E-109-066-2). Prior statistical analysis, data that served possible identification purposes have been deleted from the collected data. Therefore, research was exempted of the requirement for an informed consent form from the committee.

Lo’s Healthy and Happy Lifestyle Scale (LHHLS)

Prior to formulating the LHHLS, a data analysis on publications was carried out first. Next, the research team refined the Warwick–Edinburgh Mental Well-being Scale (WEMWBS) (Tennant et al., 2007). Together with specialist groups, through discussions and revisions, the catalogue of 14 questions was formulated. To ensure the face validity of LHHLS, the expert meetings with Taiwan, Korea, Japan and America professors were held to review the translated items of questionnaires and remove irrelevant contents. Each item of LHHLS was reviewed by experts to verify the face and content validity. The use of the 5-point Likert scale was standardized throughout the catalogue, with responses ranging from a scale of 1 (Never) to 5 (Always). To ensure the authenticity of the scale, every content had been revised according to advice and constructive criticism from a group of psychiatrists and specialists. Culturally sensitive wordings and irrelevant content have been removed. Participants were asked to rate themselves on their feelings of a happy and healthy lifestyle over the past 2 weeks. A high score on the LHHLS indicates a high standard of healthy and happy living.

Statistical analysis

LHHLS was conducted on 1,714 research participants to ensure psychological analytical features. Through factor analysis, we can observe the structural effectiveness. Concretely speaking, using the RANDBETWEEN function in Excel, 1,714 participants were randomly split into two samples. After which, the first sample (n = 857) underwent EFA while the second sample (n = 857) underwent CFA. Using SPSS statistical software (compatible with Windows IBM SPSS Statistics Ver. 24.0, NY Armonk, NY: IBM Corp) to carry out EFA. Due to factor-related assumptions, we used Varimax rotation to carry out analysis of principal components factors, then used Kaiser-Mayer Olkin (KMO) for sampling adequacy and Bartlett’s test. KMO value >0.60, while big data statistical analysis from the Bartlett’s test indicates that data is adequate in carrying out factor analysis (Tabachnick & Fidell, 2007). In consideration of variance, it shows measurement of feasibility of related concepts or structures (Hardy, 2004).

Due to multivariate skewness (−0.21) and multivariate kurtosis (−0.35), Pointing out the normal distribution of the second sample placed through CFA, a maximum likelihood estimation is required to ensure model statistics should follow ETA to obtain factor structure. Using Amos statistical software (compatible with Windows’ IBM Amos Statistics Ver. 22.0, NY Armonk, NY: IBM Corp) to carry out CFA. Usually, the Standardized Root Mean Square Residual (SRMR) should fall below 0.08 (Chang et al., 2018; Tennant et al., 2007), root mean square error of approximation (RMSEA) below 0.08 (Bentler & Bonett, 1980; MacCallum et al., 1996; Wu et al., 2015), Comparative Fit Index (CFI) and Non-Normed Fit Index (NNFI) above 0.9 (Bentler & Bonett, 1980; Lin et al., 2014) indicates a good fit. As well as a standard chi-squared (chi-square/df) smaller than 2 (Tabachnick & Fidell, 2007) or smaller than 5 (Wheaton et al., 1977). A test for validity of the internal standardized tools was carried out.

Results

Introduced the characteristics of a social population in our participants. Table 1. Social population characteristics and hospital visits of participants. Table 1 lists out the statistical features of social population in our participants.

Table 1.

Sociodemographic characteristics and hospital visiting of participants.

Variable	n	%
Gender
Male	564	32.9
Female	1138	66.4
Transgender	5	0.3
Occupation
None	302	17.6
Police officer	24	1.4
Civil servant	133	7.8
Labor worker	411	24.0
Healthcare	187	10.9
Teaching profession	301	17.6
Student	108	6.3
Others	248	14.5
Age (years)
Under 20	23	1.3
20–29	173	10.1
30–39	263	15.3
40–49	517	30.2
50–59	505	29.5
60–69	206	12.0
Above 70	20	1.2
Marital status
Never married	464	27.1
Married	1101	64.2
Divorced	98	5.7
Widowed	28	1.6
Cohabitation	13	0.8
Religion
None	570	33.3
Yes	1144	66.7
Education
None	0	0
Primary	5	0.3
Secondary	10	0.6
High school	174	10.2
Bachelor’s degree	888	51.8
Master’s degree/PhD	626	36.5
Others	3	0.001

Descriptive statistics along with both the EFA and CFA factor loadings of the LHHLS items are presented in Table 2.

Table 2.

Means, standard deviations, Cronbach’s α, and factor loadings for the items in the LHHLS.

Items	Mean (SD) (n = 1714)	EFA (n = 857)	CFA (n = 857)
Self-efficacy (α = .94)
2. I feel that I am a useful person.	4.08 (0.90)	0.71	0.72
5. I am full of energy in life and can overcome anything.	3.79 (0.89)	0.70	0.83
6. I can deal with problems very well.	3.92 (0.77)	0.84	0.81
7. I have a logical and clear thought process when faced with a problem.	3.98 (0.78)	0.84	0.77
8. I feel that I am a great person.	3.80 (0.93)	0.80	0.84
9. I have good relationships with others.	3.92 (0.78)	0.60	0.69
10. I am confident.	3.79 (0.91)	0.82	0.87
11. I can always efficiently use my knowledge to deal with problems.	3.91 (0.82)	0.83	0.82
Positive Thinking (α = .83)
1. I am optimistic about my future life.	3.73 (0.96)	0.51	0.59
3. I feel that life is carefree.	3.64 (0.95)	0.56	0.65
4. I am interested and curious of others.	3.44 (1.00)	0.81	0.40
12. I feel cared for and loved.	3.89 (0.87)	0.60	0.64
13. I am interested in things that are new to me.	3.92 (0.88)	0.67	0.59
14. I am always rejoicing in life.	3.62 (0.88)	0.65	0.79

Note. EFA = exploratory factor analysis; CFA = confirmatory factor analysis; SD = standard deviation.

Construct validity

Explorative Factor Analysis

An Explorative Factor Analysis (EFA) was conducted on a sample of 857 parents of participants. KMO value for sampling adequacy is 0.95, indicating that sample is adequate. Bartlett’s test of sphericity compares our correlation matrix to the identity matrix and results have shown that they are unrelated, thus supporting the presence of factors.

Carrying out the principal components factor analysis using Varimax rotation, which assumes each factor being related thus rotating these factors, to confirm factors. In the beginning, results confirmed the proposed 2-factor solution of all 14 items, and results supported and explained total variance 67.04% of the 2-factor solution.

Table 2 lists sub-scales of items and factor load. The theoretical factor for the design of evaluative tools and the 2-factor solution coincide. The first factor (α = .94) includes eight items, with a factor load of .60 to .84. The second subscale (α = .83) includes six items, with a factor load of .51 to .81. Each subscale scoring average to be above the passing average calculation. Table 3 lists the Pearson’s likelihood between each dimension of the LHHLS.

Table 3.

Correlation among the dimensions of the LHHLS.

LHHLS dimensions	Self-efficacy	Positive thinking
Self-efficacy	–	0.76**
Positive thinking	0.76**	–

Note. **p < .01.

Confirmatory Factor Analysis

CFA fit index is within acceptable range: CFI = 0.924, NNFI = 0.913 and SRMR = 0.048. Except RMSEA = 0.101, standard chi-square = 88.901 (chi-square = 8178.850, df = 92, p < .001). Otherwise, each factor’s factor load is as follows: Factor 1 factor load = 0.66–0.87, factor 2 factor load = 0.45–0.84. Overall, current model shows that data is an acceptable fit.

Reliability

Internal consistency of LHHLS measures with a Cronbach’s α value of .94. From Table 2, sub-dimensions of LHHLS, namely self-efficacy has Cronbach’s α value of .94 whereas positive thinking have Cronbach’s α value of .83.

Discussion

In this research, we have developed and verified LHHLS in measuring the recovery of resilience within population samples in Taiwan. The 14 items in the final version of LHHLS has a total variance of 67.04%, including two theoretical and statistical appropriate sub-scales: self-efficacy and positive thinking. The psychological scale features support 2 factor hypotheses, including construct validity (using EFA and CFA), and reliability (using Cronbach’s alpha to measure internal consistency). LHHLS abides by psychological standardized measurements and have been proven to be a simple and potentially become a standardized scale in the future. Its use is to measure whether individuals have successfully managed the impacts of COVID-19 on their adaptability.

LHHLS is made up of two scales, scoring from a range 1 to 5, where a higher scoring indicates a higher adaptability of individuals in face of COVID-19. The two items of recovery which they feel the most for is the ‘self-efficacy’ sub-dimension. They are people who ‘think themselves as useful’ and ‘have a logical and clear thought process in times of challenges’. The two tangible dimensions they understand the least is ‘positive thinking’. They are people who ‘are curious and interested about other people’ and ‘always feel happy in their lives’.

The first weighted subscale, self-efficacy, is defined as people’s belief in successfully carrying out a task that produces desirable outcomes. Where in many dimensions exists differences, including amplitude (whether the individual believes to accomplish tasks alone), universality (whether the individual believes they can complete tasks in unknown fields with their self-efficiency), energy (extent of difficulty in lowering one’s self-efficacy) (Bandura, 1977). In the first subscale of LHHLS, we used eight items to measure one’s self-efficacy. As expected, self-efficacy and recovery ability are positively related. Individuals with a lower scoring in self-efficacy are more likely to face psychological challenges in face of COVID-19.

In the second subscale, we used six items to measure positive thinking. In earlier studies, positive thinking is defined as reflective in the overall demeanor of thoughts, behaviors, feelings, and speech (McGrath, 2004), and is related to pain alleviation and health outcome predictions (Tugade et al., 2004; Tugade & Fredrickson, 2004). Following 11th September 2001, a study on stress response reported that after the terrorist attack in America, people with resilience are less likely to develop depression and psychiatric activity does not increase as well (Fredrickson et al., 2003). Another meta-analysis found that having a positive mindset helps in achieving successes in work, performance, social relationships, self-awareness, problem-solving, creativity and health (Lyubomirsky et al., 2005). As expected, positive thinking and recovery ability are positively related, allowing individuals to have constructability, creativity and to overcome challenges caused by COVID-19. In this research, resilience and self-efficacy and positive thinking have a positive relationship.

The resilience of people in face of COVID-19 and its societal impacts can be effectively understood using the LHHL-RS. Or in assessments of individuals’ resilience against such disastrous impacts. It is said that such evaluations into individuals’ psychological health and resilience have a value and it is a reliable tool. At the same time, it provides us with a goal towards encouraging interventions in crucial reconstruction of psychological health after a disaster (Lo & Shieh, 2019). This research sets the foundation for future research into education, family science and technological science through multidimensional factors of resilience evaluation of the participants from the normal population.

Because of the global threat of the biological disaster, COVID-19, it has caused tremendous consequences in our daily lives. Therefore, in times of biological virus outbreak in the future, we must be constantly equipped with healthy mental energy and consider self-efficacy and positive thinking into our healthy and happy lives. As such, to elevate our own resilience against disasters, strengthen disaster prevention and reduction and build an actionable plan to educate about healthy living.

In times of COVID-19, LHHLS conceptualizes and measures individuals’ adaptability in self-efficacy and positive thinking. However, this research has limitations. First, the study data were exclusively self-reported and may have therefore suered from shared-method variance. Second, the participants in this study were recruited from whom responded to the recruitment advertisement. Therefore, the results of this study might not be generalized to college students who did not participate in this study.

We did not investigate the validity of the LHHLS with related standards. Despite that, further research must be conducted, to use the validity of other related standards and adaptability scales to prove our findings. Despite this limitation, our overall finding states that LHHLS is reliable and valid. Also, LHHLS can also serve to devise other tools for disaster prevention and treatment plans in normal populations.

Conclusion

The LHHLS tool’s verification results present that LHHLS is reliable and valid. Therefore, LHHLS can be defined as a measurement for resilience, thus forming the LHHLS, in response to a study into how individuals and communities have been impacted by COVID-19. In other words, LHHLS contains good psychological adaptability scale analysis of features. It is recommended that LHHLS be used in research investigations into how COVID-19 has impacted society’s recovering ability, or a targeted evaluation into individuals’ psychological health in lifestyle adaptations/ resilience.

Footnotes

Acknowledgements

The authors gratefully acknowledge the contribution of the participants involved in this COVID-19 pandemic study, and would like to thank the Ministry of Science and Technology, the Ministry of Health and Welfare of Taiwan for funding interdisciplinary research team for decade.

Author contributions

Conceptualization, H.W.L. and F.H.C.; methodology, K.Y.H.; software, W.C.L.; validation, K.Y.H. and W.C.L; formal analysis, K.Y.H. and W.C.L investigation, K.Y.H. and W.C.L.; resources, H.W.L. and F.H.C.; data curation, H.W.L. and F.H.C; writing—original draft preparation, K.Y.H; writing, review and editing, W.C.L, H.W.L. and F.H.C.; supervision, H.W.L. and F.H.C.; project administration, H.W.L. and F.H.C.; funding acquisition, H.W.L. and F.H.C.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This integrated study is supported by funding from Ministry of Science and Technology of Taiwan. V.S. have led the MOST 3 years integrated project, included three subprojects (MOST 104~106-2625-M-017-001), A.L. has led an ongoing project, included four subprojects (MOST 107~110-2625-M-037-001), F.C. is the primary investigator of this MOST study (MOST 107~110-2625-M-280-001), V.S. and A.L. are also supported by the Ministry of Health and Welfare is gratefully acknowledged.

Ethical approval

This research has obtained approval from the research ethics committee in National Cheng Kung University (Certificate for standard ethics: NCKU HREC-E-109-066-2).

ORCID iDs

Kuan-Ying Hsieh

Frank Huang-Chih Chou

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