Developing and testing the feasibility of a new internet-based intervention-A case study of people with stroke and occupational therapists

INTRODUCTION

Internet-based interventions are called for within rehabilitation to meet the limited access to support for self-management after stroke. Therefore, a new intervention program, "Strategies for Empowering activities in Everyday life" (SEE) was developed. The aim of this study was to explore and describe how clients with stroke and their occupational therapists experienced the SEE intervention process and whether SEE has the potential to promote an active everyday life.

METHODS

A qualitative descriptive case study was designed. Four people with stroke (two of each sex, mean age 66,5 years) and their two occupational therapists (one of each sex) were included. A mix of data collection methods as interviews, assessments, registration forms and fieldnotes was used to uncover the participants' experiences and potential changes. Data were analysed with pattern matching.

FINDINGS

The analysed data formed three categories: "Not being able to take on the internet-based intervention", "Being facilitated in the change process of everyday life through the internet-based intervention", and "Providing a new internet-based intervention is a transition from ordinary practice". These categories included two to four subcategories that reflected aspects of SEE feasibility and acceptability with a focus on content and delivery.

CONCLUSION

The first test of the intervention indicates that the content and delivery of SEE can be feasible and acceptable both for clients and occupational therapists. The findings suggest that SEE has the potential to support clients' self-reflections and their adoption of strategies that influence engagement in daily activities and satisfaction with life in various ways. Further research with large-scale studies is needed.

Bridging the transition from homelessness: Developing an occupational therapy framework

BACKGROUND

Occupational therapists support individuals experiencing homelessness in traditional roles, and occupational therapy positions focussed specifically on homelessness appear to be growing.

OBJECTIVES

To develop and refine a framework to guide occupational therapy practice and research in homelessness.

METHOD

We developed a framework and refined it through a stakeholder consultation process conducted with 17 international occupational therapy experts using an online survey. In this survey, we presented an initial framework and requested qualitative feedback. We analyzed this qualitative data using content analysis.

RESULTS

Stakeholder feedback was categorized into eight recommendations: (1) Revision to the 'four processes'; (2) Emphasizing social justice and systems-level advocacy; (3) Reflecting intersectionality; (4) Emphasizing meaningful activity; (5) Emphasizing peer support; (6) Incorporating a focus on independent living skills; (7) Increasing a focus on an activity for addressing substance misuse; and (8) Acknowledging cognitive and physical health. Each of these recommendations was incorporated into a refined version of this framework. These recommendations and a refined version of the framework are presented in this paper.

CONCLUSIONS

We have developed and refined a framework aimed at guiding practice and research in occupational therapy in homelessness that will be evaluated in future research.

SIGNIFICANCE

Though a range of frameworks exists for guiding the practice of occupational therapists more generally, this framework represents the first that is focussed specifically on guiding occupational therapy practice and research with individuals who experience homelessness. Research and practice implications are discussed.

Interplay between negative symptoms, time spent doing nothing, and negative emotions in patients with schizophrenia spectrum disorders: results from a 37-site study

This study evaluated the relationship between negative symptoms, daily time use (productive/non-productive activities, PA/NPA), and negative emotions in schizophrenia-spectrum disorders (SSDs): 618 individuals with SSDs (311 residential care patients [RCPs], 307 outpatients) were surveyed about socio-demographic, clinical (BPRS, BNSS) and daily time use (paper-and-pencil Time Use Survey completed twice/week) characteristics. Among them 57 RCPs and 46 outpatients, matched to 112 healthy controls, also underwent ecological monitoring of emotions (8 times/day for a week) through Experience Sampling Method (ESM). RCPs spent significantly less time in PA than outpatients. Patients with more negative symptomatology spent more time in NPA and less in PA compared to patients with milder symptoms. Higher time spent in NPA was associated with negative emotions (p < 0.001 during workdays) even when correcting for BNSS total and antipsychotic polypharmacy (p = 0.002 for workdays, p = 0.006 for Sundays). Future studies are needed to explore in more detail the relationship between negative emotions, negative symptoms, time use, and functioning in individuals with SSDs, providing opportunities for more informed and personalised clinical treatment planning and research into interactions between different motivational, saliency and behavioural aspects in individuals with SSDs.

Meaningful Activities and Recovery (MA&R): a co-led peer occupational therapy intervention for people with psychiatric disabilities. Results from a randomized controlled trial

BACKGROUND

Activity and participation are critical to health and wellbeing. Limited evidence exists on how to support people with mental illness in participating in everyday activities.

AIM

To investigate the effectiveness of Meaningful Activities and Recovery (MA&R), a co-led peer occupational therapy intervention focusing on activity engagement, functioning, quality of life, and personal recovery.

METHODS

In a statistician blinded, multicenter RCT including 139 participants from seven community and municipal mental health services in Denmark, participants were randomly assigned to 1) MA&R and standard mental health care or 2) standard mental health care. The MA&R intervention lasted 8 months and consisted of 11 group sessions, 11 individual sessions, and support to engage in activities. The primary outcome, activity engagement, was measured using Profile of Occupational Engagement in People with Severe Mental Illness (POES-S). Outcomes were measured at baseline and post-intervention follow-up.

RESULTS

Meaningful Activities and Recovery was delivered with high fidelity and 83% completed the intervention. It did not demonstrate superiority to standard mental health care, as intention-to treat analysis revealed no significant differences between the groups in activity engagement or any of the secondary outcomes.

CONCLUSION

We did not find positive effects of MA&R, possibly because of COVID-19 and related restrictions. Fidelity assessments and adherence rates suggest that MA&R is feasible and acceptable. However, future studies should focus on refining the intervention before investigating its effectiveness.

TRIAL REGISTRATION

The trial was registered 24/05/2019 at ClinicalTrials.gov NCT03963245.

The impact of the BEL intervention on levels of motivation, engagement and recovery in people who attend community mental health services

BACKGROUND

Community-based day centres (DC) in Sweden provide support to people with severe mental health problems. The role of DC motivation for outcomes in terms of occupational engagement and personal recovery is yet unknown.

AIMS

To compare two groups who received DC services, one of which also received the 16-week Balancing Everyday Life (BEL) intervention. The focus was motivation for DC services at baseline and after 16 weeks of services, while also investigating the importance of DC motivation for the selected outcomes and service satisfaction.

MATERIAL AND METHODS

Sixty-five DC attendees were randomised to BEL (n = 27) or standard support (n = 38) and responded to questionnaires about motivation, the selected outcomes and satisfaction with DC services.

RESULTS

The groups did not differ on any measured aspects of motivation; nor were changes seen over time. The BEL group, but not those receiving standard support, improved from baseline to 16 weeks on occupational engagement and recovery. Motivation for attending the DC was related to service satisfaction.

CONCLUSION

The BEL program could be a viable enrichment tool in the DC context and boost occupational engagement and personal recovery among the attendees.

SIGNIFICANCE

The study provided knowledge of importance when developing community-based services while enhancing motivation.

Longitudinal Changes in Occupational Balance among Baby Boomers in Japan (1996-2016)

In Japan, the proportion of the older adult population-the post-war baby boomer generation-is increasing rapidly and presenting new problems, such as suicide among baby boomers and the burden of family care. The purpose of this study was to clarify how baby boomers changed their occupational balance between their 40s and 60s. This study used public statistical data from the Survey on Time Use and Leisure Activities published by the Statistics Bureau of Japan to analyze the longitudinal characteristics of the time allocation of baby boomers. The findings of this study showed gender differences in occupational balance among the study population. The occupational balance of men changed due to occupational transition after mandatory retirement, but that of women did not change significantly. Longitudinally examining the time allocation changes of one generation revealed that the readjustment of occupational balance is necessary during life role changes, such as retirement. Moreover, if this readjustment is not carried out properly, individuals will experience role overload and loss.

Effects of occupational balance and client-centered occupational management in a patient with schizophrenia

BACKGROUND

Occupational balance is an essential element for social participation and quality of life. However, it is difficult for patients with schizophrenia to participate in occupation and achieve occupational balance in daily life due to physical and mental symptoms.

OBJECTIVE

This study investigated the form of time use and occupational balance in a schizophrenic patient, and examined the effect of client-centered occupation-based case management.

METHODS

The research was conducted at a private center visited using one-on-one weekly client interactions for 10 weeks from September 1, 2020, and time use was analyzed using the Occupational Questionnaire (OQ) and the 2019 Life Time Survey Table of the National Statistical Office. In addition, data on work performance and satisfaction were collected using Canadian Occupational Performance Measure (COPM), and client-centered occupation-based interventions were conducted.

RESULTS

As a result of identifying the balance of work of clients, 38.46% of rest and sleep during the day, 30.77% of IADL, 17.94% of Work, 10.26% of BADL, and 2.57% of leisure. Through occupation-based case management for child care and work, which are the main goals of the client, the COPM score increased on average by 2 or more points per item, showing a positive effect.

CONCLUSION

In order to resolve the occupation imbalance of schizophrenic patients, it is necessary to closely understand the type of time use and actively intervene in client-centered occupation-based interventions.

DATA AVAILABILITY STATEMENT

Data pertinent to this report will be made available upon reasonable request to the author.

Strategies for Empowering activities in Everyday life (SEE 1.0): study protocol for a feasibility study of an Internet-based occupational therapy intervention for people with stroke

Background

Rehabilitation after stroke seldom focuses on needs related to an active everyday life and the process of change that people must undergo to adapt to an altered capacity and life situation. In particular, occupational therapy in the late phase needs to support clients in adopting sustainable self-initiated management strategies to regain daily activities and an active everyday life. To improve access to rehabilitation, the use of digital solutions has been suggested. This study aims to evaluate the feasibility of the Internet-based occupational therapy intervention “Strategies for Empowering activities in Everyday life” (SEE, version 1.0). We will investigate the feasibility of the intervention process in terms of acceptability and adherence as well as the most suitable outcome measures to evaluate SEE and improve the knowledge about the potential changes and outcomes of SEE for clients with stroke.

Methods

This feasibility study is based on a pretest posttest design without a control group. Quantitative and qualitative data will be collected from clients and staff concurrently embedded in a mixed-method design during the entire study.

Discussion

The project is a first test of a novel Internet-based occupational therapy intervention, and the research will contribute to the continued development and evaluation of the SEE programme. SEE can provide people with strategies in daily activities that can support them to live an active everyday life despite changed capacity and to improve access to rehabilitation interventions.

Trial registration

NCT04588116. Name of the registry: Strategies Empowering Activities in Everyday Life (SEE 1.0). A Web-based Occupational Therapy Intervention. URL of trial registry record. Date of registry: Trial first posted: October 19, 2020; first submitted: October 2, 2020

Identifying occupational therapy outcome measures supportive of recovery-orientated mental health services in Ireland

Purpose

No occupational therapy outcome measures have been designed specifically for recovery-orientated services.This paper aims to identify occupational therapy outcome measures relevant to mental health practice and assess them against recovery principles adopted by Irish Mental Health Services.

Design/methodology/approach

A narrative review methodology was used to appraise outcome measures against CHIME recovery principles.

Findings

A systematic search across 13 databases identified eight well-established outcome measures commonly used within occupational therapy mental health literature. The included outcome measures were appraised using a recovery alignment tool.

Practical implications

All outcome measures connected to some recovery processes. Those using semi-structured interview formats and notably the Canadian Occupational Performance Measure (COPM) had the strongest alignment to recovery processes.

Originality/value

This is the first known review which provides some validation that the included outcome measures support recovery processes, yet the measures rely heavily on therapist’s skills for processes to be facilitated. It recommends that ways to better support the process of partnership in occupational therapy mental health outcome measures be explored and further research be undertaken.

Occupational engagement scale-student: Psychometric properties in Turkish university students

Young adults pursue a career path in the face of many barriers, such as financial worries and parental influences. Engaging in occupational behaviours enables them to know themselves and the world better, and also provides them with opportunities to have experiences that help them decide on a career. This study adapts the Occupational Engagement Scale-Student (OES-S) into Turkish and examines its psychometric properties in a university sample. Participants consisted of 304 university students (149 females and 155 males). Confirmatory factor analysis confirmed the original unidimensional factor structure of the OES-S. For discriminant and concurrent validity, significant relationships were found between the OES-S and subscales of the Career Decision Scale. The internal consistency coefficient (Cronbach’s alpha) was .80. The results indicated that the OES-S could be considered as a valid and reliable tool to measure the occupational engagement of young adults.

Exploring mediators of the recovery process over time among mental health service users, using a mixed model regression analysis based on cluster RCT data

BACKGROUND

Personal recovery is associated with many significant health-related factors, but studies exploring associations between activity factors and personal recovery among service users are scarce. The aims of this study were hence to; 1) investigate if various aspects of activity may mediate change in recovery while also acknowledging clinical, sociodemographic and well-being factors; 2) explore the effects of two activity-based interventions, Balancing Everyday Life (BEL) or standard occupational therapy (SOT), on personal recovery among service users.

METHODS

Two-hundred-and-twenty-six service users were included in a cluster RCT, 133 from BEL units and 93 from SOT units. Participants commonly had a diagnosis of mood disorder and the mean age was 40. Instruments used targeted activity, mastery and functioning. A mixed-model regression analysis was employed.

RESULTS

The model tested was whether selected variables could be used to mediate the change in recovery from the start to a six-month follow-up after intervention. Participants' personal recovery increased after treatment and increased further at the follow-up. The general level of recovery was negatively related to a diagnosis of depression/anxiety, both before and after treatment, but depressed/anxious service users still increased their recovery. There were no significant relations between recovery and sex or age. The interactions between change in recovery and changes in depression/anxiety, satisfaction with activities, sex, and age were all non-significant. All possible treatment mediators included were related to change in recovery, the strongest being occupational engagement and mastery, followed by activity satisfaction and symptoms. Mediation was shown by the decrease in the effect of the time factor (from intervention start to completion) when the covariates were introduced. In all cases the time variable was still significant. When testing a model with all variables simultaneously as covariates, occupational engagement and mastery were strongly significant. There was no difference between interventions regarding recovery improvement.

CONCLUSION

The treatments were equally beneficial and were effective regardless of gender, age and diagnosis. Those who gained most from the treatment also gained in feelings of mastery and activity engagement. Activity engagement also moderated the level of recovery. To enhance recovery, interventions should facilitate meaningful activities and gaining control in life.

TRIAL REGISTRATION

The study was registered with ClinicalTrials.gov . Reg. No. NCT02619318 . Retrospectively registered: December 2, 2015.

An integrated mental health and vocational intervention: A longitudinal study on mental health changes among young adults

Aim

This study aimed to investigate changes in mental health among young adults participating in an integrated mental health and vocational support intervention according to the Södertälje Supported Employment and Education model.

Design

A prospective longitudinal pre–post intervention study of 12 months.

Methods

Instruments on depressive symptoms, quality of life, empowerment, engagement in activities and sociodemographic characteristics were administered to 42 young adults aged 19–28 years with mood disorders. Wilcoxon signed rank tests were used to assess changes in mental health.

Results

Statistically significant positive changes between baseline and 12 months were noted for quality of life and engagement in activities. Difference in empowerment scores neared significance and a statistical trend towards lower depression scores was seen, corresponding to moderate depression at baseline and less severe depression at 12 months.

Conclusions

Integrated mental health and vocational services may support young adults' mental health and is suggested to be linked to their personal recovery and clinical recovery.

A day in the life of people with severe mental illness living in supported housing

BACKGROUND

People with severe mental illness (SMI) living in supported housing (SH) struggle in everyday life and we currently lack a comprehensive body of knowledge concerning how the residents experience their day. This paper aimed to gain knowledge about how people with SMI describe a day in SH in Sweden, in particular the activities they most frequently engage in and how they experience what they do in or outside their home. Furthermore, it is important to gain knowledge of which activities motivate residents to leave the housing facility and to participate in the community. This new knowledge can help staff to encourage a recovery process among the residents.

METHODS

One hundred thirty-three people living in SH completed a time-use diary and a mixed-methods approach was applied, including calculations of what activity that was most frequently performed and a manifest content analysis addressing experiences of activity.

RESULTS

The residents had a low activity level and were often alone. Approximately one-half of the reported activities were performed in their own apartments, and generally unaccompanied. A quarter of the activities were performed in the common areas and a further quarter outside the SH. The most frequently performed activities were quiet and tranquil ones, e.g. listening to music and resting. Doing errands and group activities with staff and residents were the main activities that motivated leaving the facility. The participant experience of a day is presented in three categories: "Experiences of chosen and enforced togetherness and overcoming loneliness", "Environmental change and emotional balance can generate activity", and "Met and unmet needs for support, friendship and security".

CONCLUSIONS

The residents were generally satisfied with their quiet and tranquil lifestyle and appeared to demand little of life, which may relate to previous experiences of institutional life and can constitute a challenge for staff. The findings highlight experiences that can help to improve SH. Services need to support individually adjusted contextual stimuli and individualize the support to help residents find a good balance and motivate them to be active in and outside SH, which can support a recovery process.

Predictors of clinically important improvements in occupational and quality of life outcomes among mental health service users after completion and follow-up of a lifestyle intervention: multiple regression modelling based on longitudinal data

BACKGROUND

Balancing Everyday Life (BEL) is a new activity-based lifestyle intervention for mental health service users. An earlier study found BEL to be effective in increasing occupational engagement, occupational balance, activity level, and quality of life scores when compared with a care-as-usual group. However, it is unclear whether care context and socio-demographic, clinical and self-related factors at baseline also influence the results. Thus, the aim of the current study was to explore whether such factors could predict clinically important improvements in occupational and quality of life aspects.

METHODS

Participants were interviewed and filled out self-report questionnaires before starting the 16-week intervention (n = 133), upon completion (n = 100), and 6 months following (n = 89). Bi-variate and multi-variate statistical analyses were performed.

RESULTS

Several baseline factors were associated with clinically important improvements, but few predictors were found in the multivariate analyses. Having children was found to be a predictor of improvement in occupational engagement at BEL completion, but reduced the chance of belonging to the group with clinically important improvement in activity level at follow-up. Regarding occupational balance, having a close friend predicted belonging to the group with clinically important improvement in the leisure domain. At BEL completion, other predictors for improvements were female gender for the self-care domain, and self-esteem for the home chores domain. At follow-up, psychosocial functioning and lower education level predicted general balance. None of the factors explored in this study were found to be predictors for improvements in quality of life.

CONCLUSIONS

Few of the studied care context, socio-demographic, clinical and self-related factors were found to predict clinically important improvements in occupational engagement, activity level, occupational balance, or QOL. This study, together with previous studies showing positive results, suggests that BEL can be an appropriate intervention in both community and clinical settings, and can support improvement in occupational aspects and QOL for participants with diverse socio-demographic, clinical, and self-related characteristics.

TRIAL REGISTRATION

This study is part of a larger research project that is registered at ClinicalTrials.gov. Reg. No. NCT02619318.

A controlled study analyzing the temporal activity patterns of individuals with stroke compared to healthy adults

Introduction

The understanding of the temporal pattern of individuals can add a wider perspective to interventions. Therefore, the present study is aimed toward analysis of the temporal activity pattern of individuals with stroke compared to healthy adults.

Method

This study is a prospective, case–control, analytic research study. The study sample comprised 50 individuals with stroke and 50 individuals without disease, for 80% power with a 5% type 1 error. The Modified Occupational Questionnaire was administered to assess the temporal activity pattern. Individuals identified the activities performed at each hour of the day and data was analyzed.

Results

The temporal activity pattern of individuals with stroke differed from healthy controls; education and play activities were not part of stroke participants’ daily routines. Also, participation in work, leisure and social participation activities was significantly different for people with stroke compared to healthy controls ( p < 0.01 ). The study group assigned very low values to the activities; the value perceived by individuals differed significantly between groups ( p < 0.01 ).

Conclusion

Clinicians are in a position to enable individuals’ time use and help to engage them in meaningful activity. Individuals with stroke may benefit from a program focusing on the temporal aspect of activities.

Effectiveness of Balancing Everyday Life (BEL) versus standard occupational therapy for activity engagement and functioning among people with mental illness - a cluster RCT study

BACKGROUND

Many with a mental illness have an impoverished everyday life with few meaningful activities and a sedentary lifestyle. The study aim was to evaluate the effectiveness of the 16-week Balancing Everyday Life (BEL) program, compared to care as usual (CAU), for people with mental illness in specialized and community-based psychiatric services. The main outcomes concerned different aspects of subjectively evaluated everyday activities, in terms of the engagement and satisfaction they bring, balance among activities, and activity level. Secondary outcomes pertained to various facets of well-being and functioning. It was hypothesized that those who received the BEL intervention would improve more than the comparison group regarding activity, well-being and functioning outcomes.

METHODS

BEL is a group and activity-based lifestyle intervention. CAU entailed active support, mainly standard occupational therapy. The BEL group included 133 participants and the CAU group 93. They completed self-report questionnaires targeting activity and well-being on three occasions - at baseline, after completed intervention (at 16 weeks) and at a six-month follow-up. A research assistant rated the participants' level of functioning and symptom severity on the same occasions. Non-parametric statistics were used since these instruments produced ordinal data.

RESULTS

The BEL group improved more than the CAU group from baseline to 16 weeks on primary outcomes in terms of activity engagement (p < 0.001), activity level (p = 0.036) and activity balance (p < 0.042). The BEL group also improved more on the secondary outcomes of symptom severity (p < 0.018) and level of functioning (p < 0.046) from baseline to 16 weeks, but not on well-being. High intra-class correlations (0.12-0.22) indicated clustering effects for symptom severity and level of functioning. The group differences on activity engagement (p = 0.001) and activity level (p = 0.007) remained at the follow-up. The BEL group also improved their well-being (quality of life) more than the CAU group from baseline to the follow-up (p = 0.049). No differences were found at that time for activity balance, level of functioning and symptom severity.

CONCLUSION

The BEL program was effective compared to CAU in terms of activity engagement. Their improvements were not, however, greater concerning other subjective perceptions, such as satisfaction with daily activities and self-rated health, and clustering effects lowered the dependability regarding findings of improvements on symptoms and functioning. Although the CAU group had "caught up" at the follow-up, the BEL group had improved more on general quality of life. BEL appeared to be important in shortening the time required for participants to develop their engagement in activity and in attaining improved quality of life in a follow-up perspective.

TRIAL REGISTRATION

The study was registered with ClinicalTrial.gov. Reg. No. NCT02619318 .

Quality of Life Among People with Psychiatric Disabilities: Does Day Centre Attendance Make a Difference?

The purpose was to investigate (i) how people with psychiatric disabilities who attend day centres experience their quality of life (QoL) compared to non-attendees, (ii) differences in QoL between those who attend meeting place-oriented centres and those who attend work-oriented centres, (iii) possible correlates of QoL among day centre attendees. Ninety-three day centre attendees and 82 non-attendees completed questionnaires addressing QoL and selected correlates. No group difference was found regarding QoL. Factors related with a good QoL were high levels of self-mastery and motivation. Thus, promoting day centre attendees' self-mastery and motivation might enhance their QoL.

Wellbeing, activity and housing satisfaction - comparing residents with psychiatric disabilities in supported housing and ordinary housing with support

BACKGROUND

The home is imperative for the possibilities for meaningful everyday activities among people with psychiatric disabilities. Knowledge of whether such possibilities vary with type of housing and housing support might reveal areas for improved support. We aimed to compare people with psychiatric disabilities living in supported housing (SH) and ordinary housing with support (OHS) regarding perceived well-being, engaging and satisfying everyday activities, and perceived meaning of activity in one's accommodation. The importance of these factors and socio-demographics for satisfaction with housing was also explored.

METHODS

This naturalistic cross-sectional study was conducted in municipalities and city districts (n = 21) in Sweden, and 155 SH residents and 111 OHS residents participated in an interview that included both self-reports and interviewer ratings. T-test and linear regression analysis were used.

RESULTS

The SH group expressed more psychological problems, but better health, quality of life and personal recovery compared to the OHS residents. The latter were rated as having less symptom severity, and higher levels of functioning and activity engagement. Both groups rated themselves as under-occupied in the domains of work, leisure, home management and self-care, but the SH residents less so regarding home management and self-care chores. Although the groups reported similar levels of activity, the SH group were more satisfied with everyday activities and rated their housing higher on possibilities for social interaction and personal development. The groups did not differ on access to activity in their homes. The participants generally reported sufficient access to activity, social interaction and personal development, but those who wanted more personal development in the OHS group outnumbered those who stated they received enough. Higher scores on satisfaction with daily occupations, access to organization and information, wanting more social interaction, and personal recovery predicted high satisfaction with housing in the regression model.

CONCLUSION

The fact that health, quality of life and recovery were rated higher by the SH group, despite lower interviewer-ratings on symptoms and level of functioning, might partly be explained by better access to social interaction and personal development in the SH context. This should be acknowledged when planning the support to people who receive OHS.

How do Swedish day center attendees with psychiatric disabilities view their worker role? A structural equation modeling study

AIM

To investigate how day center attendees with psychiatric disabilities perceived their worker role and the importance of current work situation and personal factors in that respect.

METHODS

Two-hundred attendees completed the Worker Role Self-assessment and questionnaires addressing possible predictors of the worker role: current employment situation, satisfaction with that situation, and a personal factor (encompassing self-esteem, self-mastery and engagement). Structural equation modeling was used.

RESULTS

A model indicated two worker role factors; belief in a future worker role (WR1) and current capacities and routines (WR2). WR1 was positively influenced by having a job, younger age and the personal factor. Satisfaction with current work situation (usually unemployment) was negatively associated with WR1. The personal factor was single predictor of WR2. The attendees rated WR2 more positively than WR1.

CONCLUSIONS

The personal factor was crucial for both WR1 and WR2. Work-related factors were only important for WR1. The more negative rating of belief in a future worker role may be interpreted as mistrust in the services. The attendees' positive ratings of capacities indicate, however, that they had a rehabilitation potential to develop. Enhancing self-esteem, mastery and engagement may be an avenue for staff in efforts to support the attendee's worker role.

Staff ratings of occupational engagement among people with severe mental illness - psychometric properties of a screening tool in the day center context

Background

Staff who plan and organize day center activities may need to observe the attendees’ performance and progression. This led us to develop a tool for that purpose, termed General Occupational Engagement in people with Severe mental illness (GOES). The aim was to investigate its psychometric properties in terms of factor structure, internal consistency, corrected item-total correlations (CITC), convergent and discriminant validity, and test-retest stability.

Methods

Ninety-three day center attendees were assessed by the GOES and instruments addressing constructs hypothesized to be either similar to (activity level, motivation for day center attendance, perceptions of the worker role, hours spent in the day center) or divergent from the GOES (attendees’ ratings of engagement in specified occupations, self-rated health, psychosocial functioning, psychiatric symptoms). A second sample of 41 attendees were included for the test-retest analysis. Exploratory factor analysis, Cronbach’s alpha analysis, Pearson correlations and paired-samples t-tests were performed.

Results

Exploratory factor analysis indicated one factor, which was in line with the intentions of the scale. The alpha value was 0.85 and all CITC were above 0.30. The tests for convergent validity resulted in correlations ranging between 0.23 and 0.47, most of which were moderately strong and mainly confirmed the hypotheses. Discriminant validity was clearly indicated, since all correlations with the selected constructs were <0.20. GOES also showed preliminary test-retest stability (r = 0.32).

Conclusions

The GOES is ready for use in rehabilitation services and research where productive and other types of activities are of interest. It may serve as an important supplement to attendees’ self-reported occupational engagement.

Occupational engagement and cognitive functioning among persons with schizophrenia: an explorative study

BACKGROUND

Cognitive functioning may have implications for engagement in daily occupations among people with schizophrenia.

OBJECTIVES

This cross-sectional study explores relationships between time use assessed occupational engagement and cognitive functioning among persons with schizophrenia.

METHODS

Thirty-nine participants from four mental health care services in Sweden participated. The Profile of Occupational Engagement among persons with Severe mental illness (POES) and a cognitive test battery was used.

RESULTS

Higher attention and psychomotor speed and higher scores in information processing speed, immediate and delayed verbal recall, and immediate and delayed visual recall were significantly correlated with higher scores in occupational engagement. Regression analyzes revealed that information processing speed and delayed visual recall best explained the variance in occupational engagement (R²=0.36).

CONCLUSIONS

Cognitive functioning has implications for occupational engagement, and thus the ability to perform daily occupations in a balanced rhythm within various social and physical environments.

The role of empowerment and quality of life in depression severity among unemployed people with affective disorders receiving mental healthcare

PURPOSE

Sick leave and unemployment are highly prevalent among people with affective disorders. Their depression severity is disabling and inversely related to having employment. No evidence-based vocational rehabilitation exists for this target group. Knowledge is therefore needed to understand the psychosocial factors that affect depression severity in order to develop new rehabilitation interventions. This study examined relationships between depression severity and empowerment, working life aspirations, occupational engagement, and quality of life in unemployed people with affective disorders receiving mental healthcare.

METHOD

In this cross-sectional study of 61 participants, instruments on psychosocial factors and questions on descriptive sociodemographic and clinical characteristics were administered. Descriptive, correlation, and regression statistics were applied.

RESULTS

Correlation and regression analyses showed significant inverse relations between depression severity and empowerment and quality of life. The odds for more severe depression decreased with higher empowerment and quality of life. However, neither extent of engagement in daily life nor working life aspiration was related to depression severity.

CONCLUSIONS

An empowerment approach and strategies, which support the quality of life, are needed in development of vocational rehabilitation interventions, and bridging of mental healthcare and vocational services. Implications for Rehabilitation Enhancing empowerment and quality life in the return to work process can decrease depression severity in unemployed people with affective disorder. There is a need to address work issues in addition to symptom reduction in primary and mental healthcare. Bridging the service and time gap between vocational rehabilitation and healthcare is recommended for mitigating long-term unemployment for people with affective disorders who want to work.

Temperament, Character, and Self-Esteem in Relation to Occupational Performance in Individuals with Schizophrenia

Occupational therapy researchers have tried to clarify the links between occupation and state-like characteristics, such as people's experienced health, disability, and quality of life. However, to fully examine the spectrum of potential influences on occupation, trait-like features should also be investigated. This study focused on personality and self-related factors, in terms of temperament, character, and self-esteem, and how these influenced certain facets of daily occupation (activity level, occupational engagement, and satisfaction with daily occupations) in 72 adults with schizophrenia. Trait properties were associated with different facets of daily occupation. Self-esteem and the temperament dimension “persistence” explained most of the variance in both activity level and occupational engagement, whereas the character dimension “self-directedness” accounted for most of the variance in satisfaction with daily occupations. Thus, both the character and self aspects, regarded as influenced by social learning and developing over time, and the temperament dimensions, regarded as innate traits that are stable over time, exhibited such relationships. The findings highlight the role of people's trait-like properties in relation to their capacity for occupational performance, an area that has been addressed in theoretical discussions but needs to be further explored in empirical studies. If the findings of this study can be replicated in future studies, the effect of personality on occupational performance should be carefully considered in occupational therapy practice.

Relationships between Occupational Factors and Health and Well-Being in Individuals with Persistent Mental Illness Living in the Community

Purpose. This study identified relationships between occupational factors and health and well-being among individuals with persistent mental illness. Methods. There were 103 subjects assessed in regards to time spent in different occupations, activity level, satisfaction with daily occupations, and experienced occupational value. The health-related variables were self-rated health, quality of life, self-esteem, sense of coherence, self-mastery, psychosocial functioning, and psychiatric symptoms. Results. Subjective perceptions of occupational performance were consistently related to both self-rated and interviewer-rated aspects of health and functioning. While variables pertaining to actual doing showed weak or no associations with self-rated health-related variables, they exhibited moderate relationships to interviewer-rated health and functioning. Implications. The health-promoting ingredients in occupations were determined by the way occupations were perceived, rather than the doing per se. The findings indicate that perceived meaning and satisfaction ought to be prioritized when setting goals in occupational therapy practice, and, besides, that existing occupational therapy theory needs to be updated.

Perception of occupational balance by people with mental illness: A new methodology

Aims The aims were to (i) investigate initial construct validity of a tool for assessment of time allocation in occupational balance, and (ii) describe perceived occupational balance and its relationship with socio-demographics, well-being, and personal recovery among people with mental illness. Methods Satisfaction with Daily Occupations and Occupational Balance (SDO-OB) was administered to 226 persons. SDO-OB reflects balance in five occupational domains: work, leisure, home chores, self-care, and overall occupational balance. Indicators for assessing construct validity were: satisfaction with everyday occupations, occupational value, symptom severity, and psychosocial functioning. For the second aim, the data collection included socio-demographics, life quality, self-esteem, self-mastery, and personal recovery. Results Occupational balance ratings indicated the participants were either under-occupied or in balance. Few were over-occupied. Feeling in balance was related to greater well-being and recovery compared with being under-occupied. Risk factors for under-occupation were younger age (in relation to work), and higher education (in relation to overall balance). Conclusions Associations with the indicators suggest initial construct validity. The SDO-OB is promising for assessment of occupational balance among people with mental illness. Being under-occupied was detrimental to well-being and recovery, and this indicates the importance of offering more occupational opportunities for people with mental illness.

A qualitative exploration of a community-based singing activity on the recovery process of people living with mental illness

Introduction

This study first aims to qualitatively explore the benefits of a community-based singing activity taking place in Montreal, Canada. The second aim is to identify the activity’s essential components that potentially explain these benefits.

Method

An exploratory evaluative design involving qualitative descriptive methods was used. Thirteen individuals with various mental illnesses, the voice teacher and the activity coordinator participated in a group interview.

Findings

Four main benefits emerged from the participants’ interviews: (1) rediscovering identity and gaining self-confidence; (2) resuming and engaging in meaningful occupations and projects; (3) learning to collaborate with others and improving social skills; (4) improving physical condition and cognitive skills. The essential components of the activity were identified as: a normalizing environment and the absence of stigma; high expectations and support for participants; teacher-led stress relief exercises and activities; the use of singing as an activity to express emotions and stimulate cognitive functions.

Conclusion

This community-based singing activity appears to have contributed to the recovery process of its participants. There is a clear role for occupational therapists to promote, facilitate and support such activities outside traditional mental health services, since the participants were looking for occupational participation opportunities in normalizing community contexts.

Rasch Analysis of the Profiles of Occupational Engagement in people with Severe mental illness (POES) instrument

PURPOSE

The Profiles of Occupational Engagement in people with Severe mental illness (POES) instrument was developed to study time use profiles of occupations and measure the extent they are characterized by engagement. However, the dimensional factors are not known. The aim of the present study was to establish the internal construct validity of the POES using the Rasch measurement model.

METHODS

A sample of 192 outpatients in Sweden was administered the POES and data were subjected to Rasch analysis.

RESULTS

The POES showed good fit to the Rasch model after accommodation for local dependency. The nine items had high reliability as measured by person separation index, and no threshold disordering was present. Differential item functioning analysis showed no significant differences across groups of age, sex, diagnosis, or country of origin.

CONCLUSION

The POES is a unidimensional scale that represents a continuum of occupational engagement. The transformed POES sum score can be used on an interval scale to measure status and changes in occupational engagement in mental health practice and research.

Definitions of occupational balance and their coverage by instruments

Introduction

Occupational balance is an important and widely used concept in occupational therapy and occupational science. There is, however, not one unified definition in use, but several different ones, and thus instruments that measure the concept in research studies are diverse as well. Consequently, it is unclear how instruments and definitions correspond. The purpose of this study was to examine the coverage of occupational balance definitions by occupational balance instruments.

Method

Within a mixed-methods design we conducted a qualitative and quantitative content analysis of definitions and items of existing instruments. Definitions and items were extracted from articles identified in a systematic literature search. The extent of congruence and coverage between definitions and instruments was examined.

Results

The definitions used in 47 articles were structured into 19 categories. The categories which were found in most definitions were a balance of ‘various occupational patterns and areas’ (42; 89%) and ‘occupational accomplishment, performance, roles and responsibilities’ (35; 75%); 20 instruments were explored. Together they covered 16 (84%) of the 19 categories.

Conclusion

Knowing which instruments cover which dimensions of occupational balance can support occupational therapists, other health professionals and health researchers in their selection of an instrument to measure occupational balance.

Individual placement and support in Sweden - a randomized controlled trial

BACKGROUND

Currently there is no evidence on the effectiveness of Individual Placement and Support (IPS) in Sweden.

AIMS

To determine the effectiveness of IPS on vocational outcomes among people with severe mental illness (SMI) in a Swedish context. A secondary aim was to evaluate a community integration effect.

METHODS

A randomized controlled trial with a parallel design was used. Mental health outpatients with SMI were randomized to IPS or traditional vocational rehabilitation (TVR) services. The allocation status was assessor-blinded. The primary outcome was competitive employment. All vocational outcomes were collected continuously, and socio-demographic and clinical variables at baseline, 6 and 18 months. The trial is registered with ClinicalTrials.gov: NCT00960024.

RESULTS

One hundred and twenty participants were randomized. Eighty seven per cent were assessed after 6 months, and 73% after 18 months. IPS was more effective than TVR in terms of gaining employment at 18-month follow-up (46% vs. 11%; difference 36%, 95% CI 18-54), along with the amount of working hours and weeks, longer job tenure periods and income. Cox regression analysis showed that IPS participants gained employment five times quicker than those in TVR. Ninety per cent of the IPS participants became involved in work, internships or education, i.e. activities integrated in mainstream community settings, while 24% in the TVR group achieved this.

CONCLUSIONS

IPS is effective in a Swedish context in terms of gaining employment and becoming integrated within the local community. The welfare system presented obstacles for gaining competitive employment directly and it was indicated that internships delayed time to first competitive employment.

A scoping review of time-use research in occupational therapy and occupational science

BACKGROUND

Time use is a defining interest within occupational therapy and occupational science. This is evident through the range of contributions to the disciplinary knowledge base. Indeed it has been suggested that time-use methods are amongst the most established research techniques used to explore aspects of human occupation. However, the extent and nature of such activity in occupational therapy and occupational science has not been examined to date.

AIM

This study sought to map the extent and nature of time-use research in occupational therapy and occupational science journals and the extent to which studies explored the relationship between time-use and health.

METHOD

A scoping review method was used.

RESULTS

Sixty-one studies were included. Scandinavian countries contributed the largest number of studies (n = 16, 26%). While time-use diaries were used most frequently (n = 30, 49%) occupational therapists and occupational scientists have developed a range of data-collection instruments. Forty-nine studies (80%) focused on time-use in clinical or defined population sub-groups. Ten studies (16%) included an empirical examination of the relationship between time-use and health.

CONCLUSION

Future research should examine time-use and health amongst well populations across the lifespan and in different parts of the world.

The influence of daily routines on engaging in diabetes self-management

OBJECTIVE

In contrast to previous research concerning the importance of routines in occupational engagement, most of which have largely focused on the routines of children and families, in this study a qualitative methodology was used to understand how routines function in a specific occupation: diabetes self-management (DSM).

METHODS

Ten low-income women participated in a multiple-methods study that involved completing a time-geographic diary (TGD) and participating in a TGD interview.

RESULTS

Findings reveal that pre-existing routines must be changed so that they may better support engagement in DSM, and that such changes are tied to underlying habits and life situations. The experiences of study participants also showed that the distribution of daily occupations through time and across social spheres can be both supportive of and problematic for engaging in DSM. In addition, the structure and sequence of competing daily occupations influences the available time and opportunities for people to further develop their skills and become more adept self-managers.

CONCLUSIONS

The implications of these findings for occupational science and therapy are discussed.

Factors related to the return to work potential in persons with severe mental illness

OBJECTIVE

This cross-sectional study aimed at investigating the relationship between the return to work potential, according to the Worker Role Interview (WRI) assessment, and clinical characteristics and level of empowerment and occupational engagement among persons with severe mental illness who express their own interest in working.

METHODS

120 participants entered the study. The WRI, the Brief Psychiatric and Rating Scale, a sociodemographic questionnaire, the Empowerment Scale, and the Profiles of Occupational Engagement in Severe mental illness were used for data collection. Correlation and regression analyses were used for statistics.

RESULTS

The return to work potential was significantly associated with having fewer symptoms, rehabilitation support or productive activities, and higher levels of engagement and empowerment. A younger age had an inverse relation to the lifestyle component in WRI. Depressive symptoms and occupational engagement explained 42% of the variance.

CONCLUSIONS

The findings support the use of an empowerment approach, taking into account the clients' symptoms, age, and time use. In addition, involvement in vocational support and productive activities may be advantageous early on in the recovery process.

Psychometric testing of a self-report measure of engagement in productive occupations

BACKGROUND

Occupational therapists working with clients in productive occupations explicitly or implicitly assess their clients' occupational engagement.

PURPOSE

To investigate the psychometric properties of the Profiles of Occupational Engagement in People with Severe Mental Illness: Productive Occupations (POES-P) in terms of internal consistency, initial construct validation, and floor and ceiling effects.

METHOD

Participants (n = 93) from six day centres completed the data collection. Correlations between the POES-P and instruments measuring similar and dissimilar attributes, such as satisfaction, psychosocial functioning, and unmet needs, were studied.

FINDINGS

A moderate relationship was found between the POES-P and occupational satisfaction (r(s) = 0.43) and a weak one with psychosocial functioning (r(s) = 0.22). The association with researcher-assessed participant engagement was slightly higher (r(s) = 0.37), and the relationship with unmet needs was nonsignificant (r(s) = -0.15). Internal consistency of the POES-P (alpha = 0.85) was good, but the distribution of responses indicated a ceiling effect.

IMPLICATIONS

The POES-P seems promising for assessing engagement in work-like occupations but would benefit from further development.

Participation in Day Centres for People with Psychiatric Disabilities — A Focus on Occupational Engagement

Background:

Day centres are central for community participation among people with mental health problems. Understanding day centre attendees' occupational engagement is therefore important.

Method:

A total of 88 people from six day centres in four municipalities in southern Sweden completed a time-use diary, recording their occupational engagement during the most recent day at the day centre. The transcribed data were analysed using thematic content analysis.

Findings:

The main theme was being part of the spirit of togetherness and getting empowered, from which the participants' reflections could be understood.

Conclusion:

The day centres provided opportunities to be occupationally engaged and to create routines, and challenged the attendees to be more active in their daily life. Day centres have the potential to provide empowering occupations and rehabilitation for people with mental health problems and to help them towards a more participatory life.

The effect of IPS on participants' engagement, quality of life, empowerment, and motivation: a randomized controlled trial

OBJECTIVE

To investigate the effectiveness of Individual Placement and Support (IPS) with regard to non-vocational outcomes among individuals with severe mental illness.

METHODS

A randomized controlled trial was carried out, comparing IPS with traditional vocational rehabilitation. The Empowerment Scale, the Worker Role Interview, the Profile of Occupational Engagement, and the Manchester Short Assessment of Quality of Life were administered to 120 clients, at baseline, six, and 18 months.

RESULTS

IPS participants showed higher scores in quality of life (p = 0.002), empowerment (p = 0.047), and work motivation (p = 0.033) at 18 months. Within the IPS group, a significant change in QOL was shown at six (p = 0.002) and 18 months (p = 0.000), and in occupational engagement (p = 0.003; p = 0.012).

CONCLUSIONS

IPS can be part of a recovery process as individuals may increase their life satisfaction and time spent in daily occupations and community life.

Empowerment in supported employment research and practice: is it relevant?

BACKGROUND

This cross-sectional study is aimed at describing and investigating empowerment and its relationships with level of engagement in daily activities and community life, experienced stigma, psychopathology, and quality of life among people with mental illness entering supported employment.

METHOD

The following scales were administered to 120 persons: Empowerment Scale, Profiles of Occupational Engagement Scale, Manchester Short Assessment of Quality of Life Scale, Rejection Experience Scale and Brief Psychiatric and Rating Scale.

RESULTS

Higher scores of empowerment were associated with fewer symptoms and experienced stigma, a higher level of engagement in daily activities and community life, better quality of life and having work rehabilitation. Self-efficacy and self-esteem were in particular significantly correlated to depressive symptoms. Descriptive statistics enveloped the group of participants that said 'Yes I want to work' with a somewhat high mean score for empowerment, level of engagement and quality of life, but a low mean score with regard to both symptoms and experienced stigma.

CONCLUSIONS

This study advocates the importance of evaluating empowerment in supported employment research and practice. The findings suggest the importance of taking into account not only monetary aspects of having a job but also social and psychological aspects such as empowerment, reduction in experienced stigma and community integration.

Randomized Controlled Pilot Study of an Occupational Time-Use Intervention for People With Serious Mental Illness

OBJECTIVE. We assessed the efficacy and clinical utility of a new occupational time-use intervention, Action Over Inertia, designed to improve occupational balance and engagement among community-dwelling people with serious mental illness.

METHOD. Using a randomized controlled design, we assigned 24 participants to an intervention group or standard care group. Participants were community-dwelling people with serious mental illness receiving assertive community treatment services. Data on time use, occupational balance, and engagement were collected and compared at baseline and 12-wk posttest.

RESULTS. Eighteen participants completed the pilot study. Treatment group participants increased their occupational balance by spending an average of 47 min more per day in activity than the control group (p = .05). Differences in occupational engagement were not shown, but evidence of clinical utility was found.

CONCLUSION. This pilot study of Action Over Inertia has shown evidence of efficacy and clinical utility.

Occupational Engagement among University Students in Jordan: Adaptation to Careers in the Future

The main purpose of this study was to determine the level of occupational engagement among university students in one Jordanian university. The instrument used to collect data in this study was the Occupational Engagement scale-student (OES-S-14 items) developed by Cox (2008). The OES-S went through rigorous cross-cultural translation process to ensure its validity. The study surveyed 139 students who were enrolled in the vocational education courses and evaluation courses offered by the Department of Curriculum and Instruction at the Hashemite University. Results of the study indicated that participants have high level of occupational engagement. The study also indicated that students enrolled in the vocational course exhibited higher levels of occupational engagement than those enrolled in the evaluation course.

Relationships between occupational engagement and status of and satisfaction with sociodemographic factors in a group of people with schizophrenia

The present study is part of a larger project investigating occupational engagement and health in a group of people with schizophrenia. This study was aimed at extending this knowledge base with regard to occupational engagement and sociodemographic factors. Seventy-four outpatients participated in the study. The Profile of Occupational Engagement in People with Schizophrenia, the Lancashire Quality of Life Profile scale and a standardized questionnaire were used to gather data. Contrary to what was expected, occupational engagement was not associated with a certain type of schizophrenia, being younger or older, or gender. The results showed that a high level of occupational engagement was related to greater satisfaction with the participants' social and living situation, having a reliable alliance and a close friend, school-leaving age, living in a flat, and working or studying. Satisfaction with living independently, having had a recent experience of accomplishment, and working together explained 55% of the variance in occupational engagement. Occupational therapists should thus focus on and promote social engagement appropriate to the client's level of engagement, the client's opportunity and ability to work, his/her experience of accomplishment, and, most importantly, satisfaction with the home and living situation.

What Happened to the Time? The Relationship of Occupational Therapy to Time

Introduction:

Time has a reciprocal relationship with occupation: each helps to define and give meaning to the other. This paper explores how this interconnection has been embraced within occupational therapy.

Method:

Literature from a variety of disciplines was critically reviewed, in order to discern how occupational therapy has engaged with the temporal dimensions of occupation since its inception and the relevance of time to current practice.

Findings and discussion:

Although theoretical discussions demonstrate the importance of aspects of time within occupation, there has been only limited translation of these into occupational therapy practice. Aspects of time use, tempo and temporality are discussed in relation to their application to clinical practice. As the pace of life increases and humanity's relationship with time changes, this presents the profession with both challenges and opportunities.

Conclusion:

Time is a vital aspect of occupation. Occupational therapists need to return to core values of time awareness, rhythm and balance, because the profession once again needs to find time.

Activity-based assessment (BIA)--inter-rater reliability and staff experiences

The BIA method, based on assessment of patients in activities, was developed to enable reliable assessment of clients' occupational functioning. The method evaluates the patient's ego functions and capacity for activity and participation. The aims of this study were to examine inter-rater reliability for the BIA method and to compare the experiences of staff working with the BIA with those of staff using standard assessment (SA). In SA, the patient's activity problems and capacities were assessed without using any structured protocol. Four staff members worked according to the BIA method and eight according to SA. The estimation of reliability was based on data from 14 patients who went through the BIA and were assessed by five staff members. These assessments resulted in all in about 400 statements, which were classified and compared for agreement between raters. In order to address the aim concerning staff experiences, a questionnaire was filled out anonymously by the staff. The inter-rater reliability of the nine ego functions varied from 0.76 to 1.00. The scale was deemed appropriate by the BIA staff and they had significantly higher median ratings on work satisfaction and appropriateness than the SA staff. In conclusion, the inter-rater reliability of the BIA was found to be good. The BIA method also seems to have a high degree of appropriateness, constituting a promising assessment tool when occupational functioning is addressed.

Content Validity, Clinical Utility, Sensitivity to Change and Discriminant Ability of the Swedish Satisfaction with Daily Occupations (SDO) Instrument: A Screening Tool for People with Mental Disorders

A screening tool for assessing satisfaction with daily occupations among people with mental illness has been devised — the Swedish version of the Satisfaction with Daily Occupations (SDO) instrument — comprising a satisfaction scale and an activity level scale. The aim was to investigate the SDO for content validity, clinical utility, sensitivity to change and discriminant ability.

Nine occupational therapists evaluated the content validity of the SDO. Sensitivity to change was assessed on a sample of 36 clients in psychosocial occupational therapy. Discriminant ability was evaluated by comparing four samples: (1) 103 clients with a diagnosis of severe mental illness, (2) 55 clients attending an outpatient mental health clinic, (3) 36 women with a diagnosis of systemic sclerosis and (4) 40 healthy women.

The SDO rendered positive ratings regarding content validity, but some rewording of items was indicated as well as clearer instructions. Both the satisfaction scale and the activity level scale were found to be responsive to change. Discriminant ability was shown in that, in particular, the activity level score distinguished the mentally ill participants from the other samples.

The SDO was shown to reflect the targeted phenomenon satisfactorily and to be sensitive enough to detect change following an occupational therapy intervention. However, so far only the Swedish version of the SDO has been studied, but an English version is available whose cross-cultural validity should be examined.