Introduction

Korea is rapidly transitioning into a super-aged society; in 2025, adults aged 65 years and older will account for 20.3% of the total population, and this percentage is projected to reach 40% by 2050 [1]. Hence, effective adaptation to the aging process has emerged as a critical task. Aging anxiety refers to anxiety or fear of potential changes that may occur during the aging process [2]. Higher levels of aging anxiety are associated with more negative perceptions and attitudes toward aging and old age [2], increased depression [3,4], and negative effects on quality of life, preparation for old age, and successful aging [5-8]. In addition, anxiety about aging may lead to discrimination against older adults and conflict with the older generation [9], and, if sustained, may result in broader social burdens such as intergenerational conflict and increased welfare expenditures [10]. Particularly, late middle-aged adults (aged 50–64 years) [11] experience the highest levels of aging anxiety throughout their lives [12]. As a transitional group between midlife and older adulthood, they face multifaceted changes, including physiological aging, such as a decline in physical functioning, economic burdens related to retirement, and reduced income [13]. Therefore, they may experience high levels of aging anxiety. Late middle-aged adults, as part of the baby boomer generation, are expected to enter old age in abundance in the near future; thus, appropriately managing their aging anxiety is essential for enhancing individual well-being and mitigating the social burden associated with population aging.

The health status of late middle-aged adults approaching old age may influence their levels of aging anxiety. According to previous studies, late middle-aged adults report the highest level of anxiety related to health problems [14] and subjective health status is negatively correlated with aging anxiety [15-17]. As late middle age is a period with a high prevalence of chronic diseases due to physical aging [13], prevention-oriented health management strategies are of paramount importance.

Health-promoting behaviors refer to activities performed by individuals to achieve positive health outcomes and maintain a healthy lifestyle [18]. It has been reported to contribute not only to improvements in quality of life and psychological well-being but also to reducing treatment costs [18,19]. Health-promoting behaviors can maintain and enhance physical functioning and, simultaneously reduce health-related anxiety by enabling individuals to accept the physical changes and discomfort associated with aging more receptively [20]. Previous studies targeting middle-aged women and older adults have confirmed that health-promoting behavior is a mitigating factor for aging anxiety [16,20,21]; however, research focusing specifically on late middle-aged adults in the transitional period remains relatively limited, indicating the need for further studies.

Health self-efficacy is a key factor in sustaining health-promoting behaviors [19]. According to Bandura’s self-efficacy theory [22], health self-efficacy refers to one’s confidence in being able to manage one’s health and the ability to put this confidence into practice through health-management behaviors [19]. Previous studies have reported self-efficacy as a factor that alleviates aging anxiety [15,17,23,24]. However, these studies primarily focused on general self-efficacy, which reflects overall beliefs about coping abilities across diverse situations and has limitations in directly predicting the performance of specific behaviors [25]. Considering that health self-efficacy is a major predictor of health behaviors, the belief that one can manage one’s own health may serve as a psychological protective factor against aging anxiety among late middle-aged adults with a high chronic disease prevalence. Therefore, it is necessary to examine the impact of health self-efficacy on aging-related anxiety, particularly in this population.

With the transition to a super-aged society and the expansion of supply and demand for health information, the importance of health literacy—the ability to access, understand, and apply health-related information and services [26]—has become increasingly prominent. Health literacy helps individuals make informed health-related decisions and cope more effectively with health problems [26,27]. Limited health literacy may make it difficult to understand and interpret health-related information, which may increase health risks and anxiety about aging [28]. Previous studies have reported a negative correlation between health literacy and aging anxiety [28]; however, studies analyzing the effect of health literacy on aging anxiety remain limited. For late middle-aged adults who experience high levels of anxiety regarding health problems [14], it may help them accurately perceive the physical changes and health problems that arise during the aging process, thereby functioning as a factor that may alleviate aging anxiety, which warrants further investigation.

Many previous studies have addressed this age group by broadly encompassing midlife and later middle age, rather than analyzing late middle age as an independent group. However, unlike middle-aged adults who are relatively healthy and actively perform socially productive roles, late middle-aged adults are in a transitional period in which preparation for retirement, declines in health, and role changes become more pronounced; thus, they possess health and psychological characteristics that are different from those of midlife adults [29,30]. In addition, considering that late middle-aged adults tend to experience high levels of anxiety regarding health problems [14], it is necessary to examine health-related factors in an integrated manner and to identify how these factors influence aging anxiety. Accordingly, this study focused specifically on late middle-aged adults and examined the relationships among health-promoting behavior, health self-efficacy, health literacy, and aging anxiety, as well as the factors influencing aging anxiety. In doing so, this study sought to provide foundational data for the development of intervention programs to alleviate aging anxiety and support health and psychological stability among late middle-aged adults.

Aim and objectives

This study aimed to investigate the levels of health-promoting behaviors, health self-efficacy, health literacy, and aging anxiety; explore their relationships; and identify factors affecting aging anxiety among late middle-aged adults in one region. The specific objectives of this study were as follows:

1) To examine participants’ general characteristics and differences in aging anxiety according to general characteristics;

2) To investigate the levels of health-promoting behavior, health self-efficacy, health literacy, and aging anxiety among participants;

3) To analyze the correlations between health-promoting behaviors, health self-efficacy, health literacy, and aging anxiety;

4) To identify factors affecting aging anxiety among the participants.

Methods

Study design

This was a cross-sectional descriptive survey conducted to identify factors affecting aging anxiety among late middle-aged adults in one region.

Participants

Participants were recruited from the Master Sample panel of a professional online research company (Hankook Research, South Korea) and consisted of adult men and women aged 50–64 years residing in Metropolitan City B, South Korea. Eligible participants were invited from the panel by the survey company, and quotas for sex and age were applied. Individuals who understood the purpose of the study and provided informed consent to participate in the online survey were included. Considering the representativeness of the sample, panel response rate, and interim dropout rate, 2,052 panel members were randomly selected from the entire panel and invited to participate in the survey, and 294 participants accessed the survey link. After excluding individuals who did not meet the eligibility criteria, discontinued the survey, or were classified as insincere respondents, the final 164 participants (attrition rate: 44.2%) were included in the final analysis. The adequacy of the sample size was examined using a post-hoc test for linear multiple regression in G*Power 3.1.9.7 [31]. Based on a significance level (α) of .05, a medium effect size (f²) of .15, and 13 predictors (3 independent variables and 10 general characteristics), the statistical power for analyzing data from 164 participants was 90.6%, indicating that the sample size was adequate for the analysis.

Measures

1. General characteristics

Participants’ general characteristics were assessed using 10 items: sex, age, employment status, marital status, number of children, religious affiliation, number of chronic diseases, subjective health status, perceived economic status, and education level.

2. Health-promoting behavior

Health-promoting behavior was measured using the Health-Promoting Lifestyle Profile (HPLP) developed by Walker et al. [32] and modified and supplemented by Kim [33]. It consists of 42 items rated on a 5-point Likert scale ranging from 1 (“not at all”) to 5 (“very much”). The total scores range from 42 to 210, with higher scores indicating higher levels of health-promoting behaviors. The reliability (Cronbach’s α) was .92 in Kim’s study [33] and .94 in the present study.

3. Health self-efficacy

Health self-efficacy was measured using the Korean version of the Self-Rated Abilities for Health Practices Scale (K-SRAHP), originally developed by Becker et al. [19] and modified and translated into Korean by Lee et al. [34]. It consists of 24 items rated on a 5-point Likert scale ranging from 0 (“not at all”) to 4 (“very much”). The total scores range from 0 to 96, with higher scores indicating higher levels of health self-efficacy. The reliability (Cronbach’s α) was .94 in Lee et al.’s study [34] and .95 in the present study.

4. Health literacy

Health literacy was measured using the Korean version of the Short-Form Health Literacy Scale (HLS-SF-K12) originally developed by Duong et al. [35] and modified and translated into Korean by Seo et al. [36]. It consists of 12 items rated on a 4-point Likert scale ranging from 1 (“very difficult”) to 4 (“very easy”). The total scores range from 12 to 48, with higher scores indicating higher levels of health literacy. The reliability (Cronbach’s α) was .89 in Seo et al.’s study [36] and .93 in the present study.

5. Aging anxiety

Aging anxiety was measured using the Aging Anxiety Scale for Korean Middle-Aged Adults (AAS-KM), originally developed by Lasher and Faulkender [2] and modified and supplemented by Oh [13]. It consists of 23 items rated on a 5-point Likert scale ranging from 1 (“not at all”) to 5 (“very much”). The total scores range from 23 to 115, with higher scores indicating higher levels of aging anxiety. The reliability (Cronbach’s α) was .95 in Oh’s study [13] and .96 in the present study.

Data collection

Data were collected from June 10 to 16, 2025. A professional online research company (Hankook Research) conducted the survey. From the Master Sample panel registered with Hankook Research, eligible participants were randomly selected by the survey company, and quota sampling was applied by sex and by age group, with age categorized into three groups: 50–54, 55–59, and 60–64 years. The survey was administered online. Before starting the survey, an information sheet describing the study’s purpose, procedures, and ethical considerations was provided. Only those who agreed to participate were allowed to proceed. Participation was limited to one response per person, and completing the survey required approximately 15–20 min. The survey company applied predefined data quality criteria prior to data delivery, including survey completion status, missing values, repetitive response patterns across items, excessively short response times, and illogical responses. After completing its screening and quality-control procedures, the survey company provided the researchers with the final sample of 164 participants.

Data analysis

Data were analyzed using IBM SPSS Statistics 29.0. The specific analyses were as follows:

1) The participants’ general characteristics were analyzed using frequencies, percentages, means, and standard deviations. Differences in aging anxiety according to general characteristics were examined using an independent t-test and one-way ANOVA with Duncan post-hoc tests.

2) The levels of health-promoting behaviors, health self-efficacy, health literacy, and aging anxiety were analyzed using means, standard deviations, and minimum and maximum values.

3) Correlations between health-promoting behaviors, health self-efficacy, health literacy, and aging anxiety were analyzed using Pearson’s correlation coefficients.

4) Multiple regression analysis was performed with the enter method to identify factors influencing aging anxiety in the participants.

Ethical considerations

This study was approved by the Institutional Review Board (IRB) of Inje University Haeundae Paik Hospital (IRB No. HPIRB 2025-04-021-003). Before starting the survey, the participants were provided with an information sheet describing the study purpose, procedures, and personal information protection policy; participation was entirely voluntary. The participants were informed that they could withdraw at any time without any disadvantages. Informed consent was obtained electronically, and the survey proceeded only when participants selected “I agree.” All data were collected anonymously, stored on a password-protected portable storage device accessible only to the researcher, and securely kept in a locked cabinet. Data will be retained for five years after the completion of the study and then destroyed. All the survey instruments were used with the permission of the original authors or translators.

Results

General characteristics of participants and differences in aging anxiety according to general characteristics

A total of 164 participants were included, with a mean age of 56.70±4.08 years; 51.2% (n=84) were women. Employed individuals accounted for 65.9% of the sample (n=108). Among them, 78.0% (n=128) were married and 59.8% (n=98) had two or more children. A total of 57.9% (n=95) reported having no religious affiliation and 48.2% (n=79) reported having one chronic disease. For subjective health status, 57.3% (n=94) responded “Average,” and for perceived economic status, 57.3% (n=94) responded “Moderate,” comprising the majority. The highest educational attainment was college graduate or above (53.7%, n=88).

Participants’ aging anxiety differed significantly according to employment status (t=2.01, p=.046), number of chronic diseases (F=5.62, p=.004), subjective health status (F=15.15, p<.001), and perceived economic status (F=13.40, p<.001). Aging anxiety was significantly higher in the employed group and in the groups with one or two or more chronic diseases than in the group without chronic disease. It was also significantly higher among those who rated their subjective health status as “Average” or “Poor,” and among those who perceived their economic status as “Moderate” or “Low” (Table 1).

Levels of health-promoting behavior, health self-efficacy, health literacy, and aging anxiety

Participants’ health-promoting behavior averaged 3.30±0.49 on a 5-point scale; health self-efficacy averaged 2.53±0.58 on a 4-point scale; health literacy averaged 2.98±0.53 on a 4-point scale; and aging anxiety averaged 3.35±0.70 on a 5-point scale (Table 2).

Correlations among health-promoting behavior, health self-efficacy, health literacy, and aging anxiety

Participants’ aging anxiety showed significant negative correlations with health-promoting behavior (r=-.38, p<.001), health self-efficacy (r=-.31, p<.001), and health literacy (r=-.17, p=.029). Health-promoting behaviors were significantly and positively correlated with health self-efficacy (r=.36, p<.001) and health literacy (r=.40, p<.001), and a significant positive correlation was also found between health self-efficacy and health literacy (r=.57, p<.001) (Table 3).

Factors influencing aging anxiety

To identify factors influencing participants’ aging anxiety, a multiple regression analysis was performed by entering employment status, number of chronic diseases, subjective health status, and perceived economic status, which showed significant differences in aging anxiety, health-promoting behaviors, health self-efficacy, and health literacy. Categorical variables—employment status, number of chronic diseases, subjective health status, and perceived economic status—were treated as dummy variables. Prior to the analysis, assumption testing showed a Durbin–Watson value of 1.73, satisfying the range of 1–3, indicating no autocorrelation among the residuals. Tolerance values ranged from .25 to .91, and variance inflation factors (VIFs) ranged from 1.10 to 4.04, confirming no multicollinearity.

The multiple regression analysis indicated that significant factors influencing aging anxiety were: having one chronic disease (β=.24, p=.003), perceiving subjective health status as “Average” (β=.28, p=.002) or “Poor” (β=.29, p=.010), and reporting perceived economic status as “Moderate” (β=.33, p=.008) or “Low” (β=.34, p=.010). Health-promoting behavior (β=-.23, p=.003) and health self-efficacy (β=-.21, p=.010) were significant factors that decreased aging anxiety. The explanatory power of the model was 33%, and the regression model was statistically significant (F=8.93, p<.001) (Table 4).

Discussion

This study was conducted to provide foundational data for future efforts to alleviate aging anxiety among late middle-aged adults by examining the levels of aging anxiety, health-promoting behaviors, health self-efficacy, and health literacy, analyzing the relationships among these variables, and identifying the factors influencing aging anxiety among late middle-aged adults in one region.

The participants’ health-promoting behavior averaged 3.30 out of 5 points, falling between the mean score of 3.22 reported for middle-aged men [33] and 3.50 reported for middle-aged women [37] in previous studies using the same instrument. As few studies have analyzed health promoting behaviors by age group without sex stratification using the same tool, direct comparisons are limited. However, the level of health-promoting behaviors among late middle-aged adults in this study can be considered similar to that of middle-aged adults.

Participants’ health self-efficacy averaged 2.53 out of 4 points. Compared with previous research using the same instrument, this was higher than the score of 2.01 reported in a study of patients with chronic viral hepatitis [38]. Although a previous study reported a mean age of 55.72 years [38], which is similar to that of the present study, the lower level of health self-efficacy is consistent with the finding that health self-efficacy tends to decrease as the burden of chronic disease increases [39]. Because late middle age is a period with a high prevalence of chronic diseases due to physiological aging [13], late middle-aged adults may be regarded as a group in which health self-efficacy can become vulnerable. Therefore, it is necessary to develop specific intervention strategies to strengthen and support health self-efficacy among late middle-aged adults.

Participants’ health literacy averaged 2.98 out of 4 points, which was similar to the mean of 2.92 reported for adults aged 40–59 years, and higher than the mean of 2.57 reported for adults aged 60 years or older in a previous study using the same instrument [36]. Health literacy is reportedly lower among older and less educated groups [40]. In this study, the relatively low mean age of 56.7 years and high proportion of respondents with college education or higher may have influenced these findings. However, as this study used an online panel with relatively high information accessibility, repeated and expanded studies that include offline participants are needed.

Participants’ aging anxiety averaged 3.35 out of 5 points, which was higher than the mean of 2.94 reported for adults aged 40–59 years in a previous study using the same instrument [41]. In that study, individuals in their 40s comprised 46.1% of the sample, meaning that midlife adults comprised a substantial portion of the participants [41]. In contrast, the present study included only late middle-aged adults aged 50–64 years, resulting in a relatively higher mean age. As late middle age is a period in which individuals face multifaceted life-course changes, including physiological aging, such as declines in physical functioning as well as financial burdens related to retirement and reduced income [13], late middle-aged adults in this study may have exhibited higher levels of aging anxiety than middle-aged adults, reflecting differences in age and life-course characteristics.

Significant differences in aging anxiety were found according to employment status, the number of chronic diseases, subjective health status, and perceived economic status. Additionally, aging anxiety was significantly higher among participants who were employed than among those who were unemployed, which is contrary to previous studies that reported higher aging anxiety among unemployed individuals [42,43]. A previous study included middle-aged adults in their forties who actively participated in economic activities, and the anxiety associated with not having a job may therefore have been greater [42,43]. By contrast, late middle-aged adults may experience greater psychological pressure related to employment instability or the imminence of retirement, which may explain why aging anxiety was higher even among those who were employed. However, as job-related characteristics have not been examined in detail, further studies that incorporate these factors are required. Participants with one chronic disease and those with two or more chronic diseases reported significantly higher aging anxiety than those with none. This finding is partly consistent with a previous study of middle-aged women showing higher aging anxiety among individuals with a disease [21]. Additionally, aging anxiety was significantly higher among participants who rated their subjective health status as “Average” or “Poor,” and those who perceived their economic status as “Moderate” or “Low,” which is similar to findings from previous studies involving middle-aged adults [15-17,44].

Participants’ aging anxiety showed significant negative correlations with health-promoting behaviors, health self-efficacy, and health literacy. This is consistent with previous research reporting a negative correlation between health-promoting behaviors and aging anxiety among middle-aged adults [21,45-47] and aligns with prior findings revealing that higher general self-efficacy is associated with lower aging anxiety [15,17,23,24]. Although few studies have directly examined the relationship between health literacy and aging anxiety, prior research has reported that higher health literacy is associated with a greater likelihood of experiencing successful aging [40,48], which partially supports the present findings.

The significant factors influencing aging anxiety in this study were number of chronic diseases, subjective health status, perceived economic status, health-promoting behaviors, and health self-efficacy. First, aging anxiety increased significantly among participants with one chronic disease, suggesting that the initial diagnosis of a chronic disease may act as a turning point that increases the awareness of physical decline and intensifies anxiety. By contrast, having two or more chronic diseases did not significantly influence age-related anxiety. Reports indicate that individuals often experience emotional responses similar to a crisis during the early stages of chronic disease diagnosis, and then adapt over time as disease management experience increases [49]. Therefore, even if additional diseases are diagnosed, an increase in aging anxiety may be buffered by adaptation. Therefore, it is necessary to establish educational and emotional support systems that reduce psychological shock at the time of initial diagnosis and assist adaptation among late middle-aged adults, for whom the risk of developing chronic diseases becomes more pronounced. However, as this study did not differentiate diseases by type, severity, or duration, future studies should consider these factors to verify the relationship between the number of chronic diseases and aging anxiety.

Subjective health status was also identified as a significant factor influencing aging anxiety, with significantly higher aging anxiety among participants who perceived their health status as “Average” or “Poor.” This finding is similar to that of previous studies involving middle-aged adults [15-17,24,50]. Late middle-aged adults are likely to perceive their health negatively because of declining physical functioning and chronic diseases [13]. Therefore, supporting late middle-aged adults in perceiving their health status more positively may be an effective strategy for preventing aging anxiety. To achieve this, psychological education and cognitive interventions that strengthen positive health perceptions are needed, in addition to physical health management.

Perceived economic status was another significant factor influencing aging anxiety, and aging anxiety was significantly higher among participants who perceived their economic status as “Moderate” or “Low.” This result was consistent with that of a previous study involving middle-aged adults [13]. Late middle-aged adults face substantial financial burdens as their income decreases with retirement, while expenditures increase due to illness, children’s marriage, and preparation for old age [51]. They are also less able to rely on their children later in life because of weakened traditional norms of familial support [13]. Economic vulnerability may worsen aging anxiety. Therefore, to alleviate the anxiety among late middle-aged adults, it is necessary to establish social support systems that promote continued economic activity and strengthen income security for later life.

Higher levels of health-promoting behaviors were associated with significantly lower aging anxiety, consistent with previous research involving middle-aged women and older adults [16,20,21]. As individuals age, lifestyle factors may exert a stronger influence than genetic factors [52]. Health-promoting behavior not only helps maintain and improve physical functioning but may also promote more receptive acceptance of physical changes and discomfort associated with aging [20]. This may positively influence the overall health status and reduce health-related anxiety later in life. Therefore, strengthening specific health-promoting behaviors such as physical activity, nutritional management, and chronic disease management from late middle age may represent an important community nursing intervention strategy for alleviating aging anxiety.

Higher levels of health self-efficacy were also associated with significantly lower aging anxiety, which aligns with previous studies that identified self-efficacy as a factor alleviating aging anxiety in middle-aged adults [15,17,23,24,53]. Since late middle age is a period when health-related anxiety becomes prominent because of physical aging and the increased prevalence of chronic diseases [13,14], believing in one’s ability to manage and practice health behaviors may enhance perceived control over health problems during the aging process, thereby reducing aging anxiety. Therefore, tailored education and support group activities should be developed and applied as nursing interventions to enhance health self-efficacy among late middle-aged adults.

Although health literacy was significantly correlated with aging anxiety in this study, it did not emerge as a significant influencing factor in the regression analysis. This suggests that, although health literacy is related to aging anxiety, knowing and using health information alone may not be sufficient to reduce emotional outcomes such as aging anxiety when other variables are considered together. In this study, health-promoting behavior, which translates information into action, and health self-efficacy, which supports such practice, were identified as variables that more directly explained aging anxiety. Nevertheless, health literacy showed significant positive correlations with health-promoting behavior and health self-efficacy, and previous studies reported that health literacy influences health-promoting behavior and self-efficacy [54,55]. Therefore, health literacy may have an indirect effect on aging anxiety through health-promoting behaviors and health self-efficacy; this mediating pathway should be statistically verified in future research. Additionally, because this study used an online panel, the sample may have been biased toward individuals with high access to information, and the effect of health literacy may have been underestimated. Future studies should include offline participants to strengthen generalizability.

As this study collected data through an online panel-based web survey of late middle-aged adults in one region, individuals with limited access to the internet or smart devices or those who were unfamiliar with the digital environment may have been relatively underrepresented in the sampling process. In addition, because the study included participants from only one region, regional characteristics may have been reflected, limiting the representativeness of the sample and constraining the generalizability of the findings to the overall population of late middle-aged adults. Additionally, causal relationships among the variables could not be inferred from a cross-sectional descriptive survey using self-report measures. Nevertheless, this study is meaningful in that it identified the level of aging anxiety and the major factors influencing it among late middle-aged adults, a group for which evidence remains limited. These findings may serve as foundational data for developing community nursing interventions, including programs to enhance health-promoting behaviors and health self-efficacy, and to alleviate aging anxiety among late middle-aged adults.

Conclusions

This study found that the number of chronic diseases, subjective health status, perceived economic status, health-promoting behaviors, and health self-efficacy were factors influencing aging anxiety among late middle-aged adults. Although health literacy did not have a statistically significant direct effect on aging anxiety, the findings suggest the need for follow-up research to clarify its effect through mediating variables, considering its significant correlation with health-promoting behaviors and health self-efficacy. These results provide foundational data for developing tailored nursing interventions and educational programs to effectively alleviate aging anxiety and promote the physical and psychological well-being of late middle-aged adults during their transition to older adulthood.

Based on the findings of this study, the following recommendations are proposed: First, to alleviate aging anxiety among late middle-aged adults, it is necessary to develop and apply tailored educational and intervention programs that strengthen health-promoting behavior and health self-efficacy in community-based healthcare settings; follow-up research is required to verify the effects of such programs on aging anxiety and health-related indicators. Second, further research is recommended to examine the mediating effects of health self-efficacy and health-promoting behaviors on the relationship between health literacy and aging anxiety. Third, because this study targeted late middle-aged adults in one region who were able to respond to an online survey, repeated and expanded studies using diverse methods, including offline surveys in other regions, are needed to enhance the generalizability of the findings.

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