Positive psychology offers a promising framework for enhancing mental health, particularly among maintenance hemodialysis (MHD) patients, whose psychological well-being is often compromised. This study aimed to develop and validate a Chinese version of the PERMA Profiler, tailored to assess flourishing in MHD patients and provide a reliable research tool.

Following the translation and cultural adaptation of the original PERMA Profiler, 376 MHD patients were surveyed to assess its psychometric properties. Analyses included item analysis, exploratory and confirmatory factor analysis, criterion validity, and reliability testing.

The Chinese version retained all original items and exhibited strong psychometric properties. By validity analysis, the KMO value was 0.871. Factor analysis identified two dimensions: positive experience and self-actualization, accounting for 57.7% of the variance. Model fit indices (χ²/df = 3.23, RMSEA = 0.095) were acceptable. The scale showed strong internal consistency (Cronbach’s α = 0.914) and test-retest reliability (r = 0.764).

The PERMA Profiler, adapted for a Chinese cultural context, is a reliable and valid tool for assessing flourishing in MHD patients. It offers a robust foundation for research and intervention to improve mental health outcomes in this population.

Flourishing, a construct rooted in positive psychology, encapsulates optimal mental health and well-being. Seligman, the pioneer of positive psychology, proposed that well-being is a constant theme of positive psychology and can be measured by the level of flourishing. The ultimate goal of positive psychology is to improve the individual’s flourishing [1]. Originating from the pioneering work of Seligman, flourishing is defined through the PERMA model, which identifies five core elements: Positive Emotion, Engagement, Relationships, Meaning, and Accomplishment [2]. It is believed that the experience of flourishing occurs when a person feels positive emotions, engages in interesting activities, has positive relationships, feels meaning and purpose in life, and makes important personal achievements. Each of these characteristics has been proved to contribute to flourishing by researches [3]. Individuals can independently pursue the above characteristics in order to be flourishing and those characteristics can be independently measured, which provides a more effective and feasible theoretical framework for the evaluation and promotion of flourishing and is worthy of further exploration. The PERMA framework provides a practical and comprehensive basis for evaluating and promoting flourishing, making it an invaluable tool in psychological research.

Maintenance hemodialysis (MHD) patients are a special group in society, which refers to patients with end-stage renal disease who have been undergoing hemodialysis for three months or more [4]. Although MHD can regulate the kidney function of patients and prolong their survival to a certain extent, the long continuous treatment will lead to a variety of complications in patients, and the burden of medical expenses will aggravate the social pressure of patients, significantly impact their quality of life [5,6,7]. However, research suggests that chronic illness may prompt individuals to re-evaluate their life priorities and derive meaning, potentially fostering psychological resilience and flourishing [8]. Maintenance hemodialysis (MHD) patients, a group burdened by chronic illness and associated psychosocial stressors, present unique challenges and opportunities for studying flourishing. While MHD prolongs life, it imposes significant physical, emotional, and financial strains, underscoring the importance of evaluating and fostering flourishing in this population.

Several tools have been developed to assess flourishing, including the Mental Health Continuum Scale developed by Keyes in 2005 [9], and its simplified version was revised in Chinese by Yin Keli in 2012 [10]. The Flourish Index with seven dimensions including eight items compiled by Diener et al. in 2010 [11], and the Flourish Index and Secure Flourish Index proposed by VanderWeele in 2017 [12] to measure the level of the individual’s flourishing from the perspective of psychological and material security. However, these instruments vary in their conceptualization and measurement dimensions, often resulting in complexity and limited direct applicability. In contrast, the PERMA Profiler (PP), developed by Butler and Kern, stands out for its theoretical grounding and ease of use [13].

Based on Seligman’s PERMA model, it enables a multidimensional yet straightforward assessment of flourishing. The Profiler has demonstrated strong psychometric properties and cross-cultural applicability in various populations, including those in the United States, Australia, and Asia [13,14,15,16,17]. Adaptations in workplace settings and among Asian populations, such as Japan and Korea, have further validated its relevance across diverse contexts [16, 17].

Despite its application across diverse cultural contexts, the PP had yet to be validated in Chinese populations, particularly among MHD patients. This study addresses this gap by localizing and validating a Chinese version of the PERMA Profiler to assess its reliability and validity within this specific demographic.

The English version of the PERMA Profiler was translated and culturally adapted for Chinese MHD patients following a rigorous process. Permission to use the scale was obtained from the original author, Margaret L. Kern. The translation process adhered to a novel translation model based on Brislin’s classic back-translation framework. First, the scale was independently translated into Chinese by two bilingual experts. Their translations were reviewed and consolidated into a forward-translation version through discussion. Next, two additional bilingual experts performed back-translation independently, comparing it with the original English version to identify discrepancies. Revisions were finalized after thorough group discussions. Cultural adaptation was conducted using the Delphi method [18]. A panel of six experts with extensive experience in hemodialysis nursing, psychology, and medical translation evaluated the content for cultural relevance and clarity. The purposive sampling method was used to select MHD patients for cognitive interviews to test the consistency of different patients’ understanding of the meaning of scale items.

Participants

A convenience sample of MHD patients was recruited from three tertiary hospitals and one secondary hospital in Shanghai between October and November 2022. Inclusion criteria required participants to be aged 18 years or older, have undergone hemodialysis for at least three months, and be in stable condition. Based on the requirement of sample size being 5–10 times the number of items for factor analysis [19], 376 valid questionnaires were obtained out of 406 collected, yielding an effective response rate of 92.61%. The excluded questionnaires included those from patients with less than three months of dialysis, individuals with incomplete responses, and those with inconsistent answers. The final sample consisted of 220 male and 156 female participants, with a mean age of 58 ± 13.4 years and a mean dialysis duration of 7 ± 6.6 years.

The instruments

Sociodemographic information (e.g., gender, age, education level, marital status, employment status) and disease-related details (e.g., dialysis duration, number of comorbidities, renal transplantation history, perceived disease burden) were collected using a self-designed questionnaire.

The Chinese version of the PERMA Profiler consists of 23 items assessing nine dimensions, including five core dimensions of flourishing (positive emotion, engagement, relationships, meaning, and accomplishment), with 15 items (three per dimension). Eight supplementary items assess general well-being (1 item), negative emotion (3 items), physical health (3 items), and loneliness (1 item). The significance of these eight additional items, according to the researchers, is that they can prevent respondents from reacting while filling out this measuring instrument by addressing their feelings of loneliness and negative mood; And they can also give some helpful additional information [13, 14]. Each item is rated on a scale of 0–10, with higher scores indicating greater flourishing. Dimension scores are calculated as the mean of corresponding item scores, while the overall flourishing score is the mean of the core dimensions plus the general well-being score.

The MHC-SF, validated in Chinese populations, was used to assess criterion validity. It consists of 14 items measuring emotional, psychological, and social well-being, with scores ranging from 0 (never) to 5 (daily). Higher scores indicate better mental health.

The MHC-SF was initially developed by Keyes [9] in 2005, Validated in Chinese populations, and was used to assess criterion validity. It consists of 14 items, which are divided into three subscales: emotional well-being (3 items), psychological well-being (6 items), and social well-being (5 items) [10]. A scale of 0 to 5 was scored, with 0 (never) and 5 (daily). Participants self-rated how often they felt the problem in the past two weeks to a month. The score of the scale and each subscale is the average score of the corresponding item, and higher scale scores indicate better mental health.

Data collection

Questionnaires were distributed to eligible MHD patients using convenience sampling and collected on-site. A subset of 20 participants was re-evaluated 2–3 weeks later to assess test-retest reliability.

Data analysis

Data were analyzed using IBM SPSS and AMOS software. The item analysis [20] was conducted to evaluate item discrimination. Validity testing included content validity [21], exploratory factor analysis (EFA) [22], confirmatory factor analysis (CFA) [23], and criterion validity [24]. Reliability was assessed using internal consistency (Cronbach’s α) [25] and test-retest reliability [26].

Ethics

This study was conducted according to the guidelines of the Declaration of Helsinki (2013) and approved by the Medical Ethics Committee of Naval Medical University. All participants provided informed consent, and their privacy was strictly protected throughout the study.

Step 1: Two translators (one of whom is an associate professor) translated the original English version of the PP into Simplified Chinese. Step 2: Two other translators (one of whom is a postdoctoral researcher) reviewed and consolidated the translations, resulting in a forward-translation version of the PP. Step 3: Two translators (both with doctoral degrees) independently back-translated the consolidated version into English and compared it with the original to identify discrepancies. Step 4: The scale was modified accordingly through group discussion within the research group.

Step 5: A panel of six experts in hemodialysis nursing management, nursing psychology, and medical English, with an average of 24 years of experience, assessed the translation. They suggested modifications based on theoretical knowledge and practical experience, and evaluated each item’s relevance to the concept being measured, contributing to the calculation of the scale’s content validity.

Step 6: Two rounds of cognitive interviews were conducted with 19 MHD patients. In the first round, items P2, E3, N2, and H3 were revised based on respondent feedback, literature review, and group discussion (details in Appendix 1). After the first round, four items were revised for better clarity, and no further revisions were necessary after the second round. The finalized Chinese version of the PERMA Profiler was completed.

The coefficient of variation method, critical ratio method, and correlation coefficient method were used for item analysis. Among them, the coefficient of variation method was performed using standard deviation (S) and coefficient of variation (CV) to indicate the sensitivity of the measured items. The score of each item of the scale was statistically calculated, and the larger S and CV of the item indicated that the item had a better ability to differentiate. The criteria for item deletion in this study were S < 0.75 or CV < 0.15 [27].

The total scores of flourishing and other dimensions (general well-being, negative emotion, physical health, loneliness) are ranked by the critical ratio method. The top 27% and bottom 27% of each section’s scores are classified as high group and low group, respectively. Using independent sample t-tests, the high and low score groups for all items were analyzed for differences, and the critical ratio (CR) was calculated. In this study, a CR < 3 and P > 0.05 indicated that an item demonstrated a certain level of discrimination [28]. The CR value in this context corresponds to the t-value derived from the t-test, with the term “CR” used as its designation. The standard deviation (SD) range for all items was 2.212–3.103, all greater than 0.75, and the Coefficient of Variation (CV) was 0.311–0.805, all greater than 0.15. The CR values for all dimensional items were greater than 3, while the correlation coefficients (r) were all greater than 0.400 (P < 0.001), as shown in Table 1. These findings indicate no need to exclude any items from the scale [29, 30].

^** indicates P < 0.001.

Content validity

The content validity of the scale was assessed using the Content Validity Index (CVI), which included both the Item Content Validity Index (I-CVI) and the Scale-Content Validity Index (S-CVI). The S-CVI was further divided into the Scale-Level Content Validity Index/Universal Agreement (S-CVI/UA) and the Scale-Content Validity Index/Average (S-CVI/Ave). In this study, S-CVI/Ave was used to represent the scale-level content validity, calculated as the average of the I-CVI values for all items. The I-CVI for each item was determined by dividing the number of experts rating the item as 3 or 4 by the total number of experts. A scale is generally considered to have good content validity when I-CVI ≥ 0.78 and S-CVI/Ave ≥ 0.90. If the CVI is found to be low, researchers are advised to communicate with experts, incorporate their feedback, and conduct group discussions within the research team to revise the items as needed [31].In this study, the I-CVI for the scale ranged from 0.83 to 1.00, with R1 and A3 items having an I-CVI of 0.83. The S-CVI/Ave was 0.985, exceeding the threshold of 0.90, indicating that the scale had good content validity [32].The detailed content validity scores provided by experts are presented in Table 2.

Structure validity

Using the cross-validation method, the collected sample size was stratified and randomly sampled by the hospital. The data were divided into two groups (N1 = 130 and N2 = 246) for EFA and CFA, respectively.

Exploratory factor analysis

This study applied EFA to assess the structure of the scale. The suitability of the scale for factor analysis was determined based on the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy (KMO > 0.5) and a significant Bartlett’s test of sphericity (P < 0.05). Principal component analysis and varimax orthogonal rotation were used to extract common factors with eigenvalues greater than 1 [33]. The KMO measure was 0.871, and Bartlett’s test of sphericity was significant (χ² = 1117.522, P < 0.001), confirming the suitability of the data for factor analysis [34].Two factors with eigenvalues greater than 1 were extracted, explaining a cumulative variance of 57.688% [35]. The dimensions of positive emotion and relationships were merged into a single factor, “Positive Experience,” while engagement, meaning, and accomplishment were merged into “Self-Actualization.” The eigenvalues and variance contributions are detailed in Table 3.

Confirmatory factor analysis

This study applied CFA for validation. The study employed structural equation modeling to evaluate the model fit, using indices such as the chi-square to degrees of freedom ratio (χ²/df), Root Mean Square Error of Approximation (RMSEA), Goodness of Fit Index (GFI), Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), and Incremental Fit Index (IFI). RMSEA values below 0.1 indicate good fit, with values under 0.05 indicating excellent fit. A χ²/df ratio between 0 and 3 suggests good fit, while a ratio between 3 and 5 is considered acceptable. Other indices should ideally exceed 0.85 [36]. The two dimensions obtained by EFA were used for model fitting, and the results of model fitting indices showed χ²/df = 3.234, RMSEA = 0.095, GFI = 0.858, CFI = 0.894, IFI = 0.895, and TLI = 0.875, indicating acceptable model fit [37] (Fig. 1).

Standardized two-factor structural equation model of PERMA Profiler (PP)

Full size image

Criterion validity

MHC-SF was distributed simultaneously in one of the hospitals, and 192 valid questionnaires were collected with convenience method. Spearman correlation analysis between the PP and the MHC-SF scores showed a significant positive correlation (r = 0.686, P < 0.001), supporting good criterion validity [24].

Based on the original intention of the PP scale, the average of the scores of the two dimensions of Positive experience and Self-actualization plus the separate Overall well-being, a total of 16 items, was used as the score for the flourishing total, and therefore the flourishing total was taken as a whole dimension to analyze its Cronbach’s ‘s alpha and test-retest reliability. Cronbach’s α coefficients for the “Positive Experience” and “Self-actualization” dimensions were 0.803 and 0.902, respectively, with an overall Cronbach’s α 0.914 for flourishing. Test-retest reliability was assessed in a subset of 20 participants, with a correlation coefficient of 0.764 for flourishing. The test-retest reliability for the “Physical Health” dimension was the lowest (r = 0.546). Reliability metrics for all dimensions are summarized in Table 4.

^* indicates P < 0.05, ^** indicates P < 0.001.

This study aimed to validate and adapt the PERMA Profiler for assessing flourishing among Chinese MHD patients, a population that faces unique physical, psychological, and social challenges. The findings contribute to a deeper understanding of flourishing in a culturally specific context and underscore the importance of cross-cultural validation in psychological research.

The scale demonstrated excellent psychometric properties, with all items retained and high content validity indices (CVI > 0.8). However, two items—“To what extent do you receive help and support from others when needed?” and “How often are you able to handle your responsibilities?”—had relatively lower item-level CVIs (0.83). These results likely reflect cultural differences. In the Chinese context, seeking external support may contradict societal values of self-reliance, and the concept of handling responsibilities may lack specificity in everyday discourse compared to Western cultures. These findings highlight the interplay between cultural context and psychological constructs, warranting careful consideration in cross-cultural scale adaptation.

The combination of the Positive Emotion and Relationships dimensions into the Positive Experience factor aligns with Fredrickson’s broaden-and-build theory, which posits that positive emotions strengthen interpersonal relationships [38]. In Chinese culture, emotional states are deeply influenced by interpersonal harmony, which may explain the overlap observed in this study. In the original version of PP, the content of positive emotion dimension, such as happiness, satisfaction, and feeling positive, are closely related to good relationships and often require good interpersonal interaction to produce such positive emotions. The feelings of being loved and being satisfied with interpersonal relationships in the relationships dimension are also related to positive emotions to some extent, so the combination of positive emotion and relationships dimension in the results of this Chinese revision is reasonable.

The merging of the Engagement, Meaning, and Accomplishment dimensions into the Self-Actualization factor reflects the interconnected nature of these constructs in the context of MHD patients. In the cognitive interviews of MHD patients in this study, the patients usually associated the meaning of life with the goal, and generally did not make a special distinction. Studies have highlighted the significant overlap between life meaning and goal achievement, particularly in populations experiencing chronic illness [22, 39]. For MHD patients, engagement in meaningful activities often serves as a pathway to a sense of purpose and achievement, which may explain the dimensional convergence observed. In summary, the combination of these three dimensions in this study also has a certain theoretical and practical basis.

While the confirmatory factor analysis yielded acceptable fit indices, the RMSEA slightly exceeded the conventional threshold of 0.08. This outcome may be attributed to the unique psychological profiles of MHD patients, whose experiences with chronic illness and long-term treatment differ significantly from general populations. Nevertheless, the scale’s overall psychometric properties suggest its suitability for this target group.

The explained variance of error for items F1-E3, F2-R2, and F2-R1 was relatively low. Therefore, the researchers conducted a detailed review of the items and their corresponding dimensions. The content of Item E3 is: “How often do you lose track of time while doing something you enjoy?” This item primarily examines an individual’s state of concentration and immersion when engaging in activities they are passionate about. According to Maslow’s hierarchy of needs theory, self-actualization refers to the state where individuals fully realize their potential and pursue inner satisfaction [40]. “doing something you enjoy” reflects the realization of self-worth and inner fulfillment, while “lose track of time” signifies a flow experience [41]. This indicates a heightened state of concentration where individuals become deeply immersed in their current tasks, altering their perception of time and deriving profound satisfaction from the experience. Therefore, including this item in the self-actualization dimension is appropriate. The content of Item R2 focuses on the subjective perception of being loved. When individuals perceive themselves as loved, it often triggers a series of positive emotional experiences, such as satisfaction with intimate relationships and a sense of happiness [42]. The content of Item R1 not only addresses the individual’s behavior in accepting help and support from others when facing needs but also their internal emotional experiences. Accepting support is a positive social interaction that can enhance an individual’s happiness and life satisfaction [43]. Therefore, including these two items (R2 and R1) in the dimension of positive emotional experiences is appropriate.

The retest correlation coefficients between the scores of all dimensions of flourishing were statistically significant after 2–3 weeks, among which the retest correlation coefficient of physical health dimension was the smallest, only 0.546. The items involved in the physical health dimension are mainly the evaluation of the health degree of MHD patients, and the physical conditions of such patients have different changes during dialysis, such as gradually feeling weak, unable to stand or even fainting with the duration of each dialysis [44]. However, the investigation time of those patients was not fixed in the early or late stage of dialysis, so it was considered that the scores of patients in this dimension were significantly different between the two times. Based on the reliability and validity test results in this study, the Chinese version of PP has good reliability and validity.

MHD:

maintenance hemodialysis

PP:

PERMA Profiler

MHC-SF:

Mental Health Continuum Short-Form

CV:

Coefficient of Variation

CR:

Critical Ratio

I-CVI:

Item-content validity Index

S-CVI:

Scale-Content Validity Index

S-CVI/Ave:

Scale-Content Validity Index/Average

CFA:

Confirmatory factor analysis

EFA:

Exploratory Factor Analysis

KMO:

Kaiser-Meyer-Olkin measure of sampling adequacy

RMSEA:

Root-mean-square error of approximation

CFI:

Comparative fit index

GFI:

Goodness-of-fit index

TLI:

Tucker and Lewis index

IFI:

Incremental Fit Index

χ ²/df:

Chi-Square to Degrees of Freedom Ratio

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Author notes

In this study, JC, JW, and LZ contributed to design of the study. QYQ, LHY, QXZ, and QYL were involved in collected the data and analyzed the data. JY, YL, and LYG prepared the manuscript. JC and JW reviewed the manuscript.

Correspondence to Jing Wu or Jing Chu.

This study was conducted according to the guidelines of the Declaration of Helsinki (2013) and approved by the Medical Ethics Committee of Naval Medical University. All participants gave written informed consent.

Not applicable.

The authors declare no competing interests.

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