Occupational balance and satisfaction with daily occupations in persons with depression or anxiety disorders

ABSTRACT

Introduction: Occupational balance and satisfaction with daily occupations are two central concepts in occupational science. The aim of the present study was therefore to explore associations between different aspects of occupational balance and satisfaction with daily occupations. A second aim was to explore whether different aspects of occupational balance predicted satisfaction with daily occupations 12 months later.

Methods: The present study had an exploratory correlational longitudinal pilot study design and was part of a project in which the Tree Theme Method was evaluated for patients with depression and/or anxiety disorders. Data collected directly after the intervention (n=107) and 12 months later (n=84) were used in the present study. The Occupational Balance Questionnaire (OBQ) and the Satisfaction with Daily Occupations (SDO) were used, and binary logistic regressions were used to explore associations between them.

Results: Statistically significant associations were found between the following aspects of occupational balance: Balance between work, home, family, leisure, rest, and sleep; Having neither too much nor too little to do during a regular week; Satisfaction with time spent in rest, recovery, and sleep and satisfaction with daily occupations directly after the intervention. The occupational balance item Balance between energy-giving/energy-taking occupations directly after the intervention predicted satisfaction with daily occupations 12 months later.

Conclusion: This study provides some support for the assumption about an association between occupational balance and satisfaction with daily occupations. Studies with larger sample sizes and in other cultures are recommended to confirm the presence of these associations and/or to find other associations.

简介： 生活活动平衡和对日常活动满意度是生活活动科学的两个核心概念。因此，本研究的目的是探讨生活活动平衡和对日常活动满意度的不同方面。第二个目的是探索生活活动平衡的不同方面是否能预测 12 个月后对日常活动的满意度。方法：本研究具有探索性相关纵向试点研究设计，是一个项目的一部分。在该项目中，为抑郁症和/或焦虑症患者对树主题方法进行评估。干预后直接收集的数据 (n=107) 和 12个月后的数据 (n=84) 用于本研究。使用生活活动平衡问卷（OBQ）和日常活动满意度表（SDO），并使用二元逻辑回归探索它们之间的关联。结果：在生活活动平衡的以下方面之间发现统计学上显著相关：工作、家、家庭成员、休闲、休息和睡眠之间的平衡；在正常的一周内没有太多或太少的事情要做；干预后对休息、恢复和睡眠时间的满意度以及对日常活动的满意度。生活活动平衡项目，干预后提供能量活动/消耗能量活动之间的平衡，预测了12个月后对日常活动的满意度。结论：这项研究为关于生活活动平衡与日常活动满意度之间的相关性的假设提供了一些支持。建议进行更大样本量和其他文化的研究，以确认这些相关性的存在和/或寻找其它相关性。

Introducción: El equilibrio ocupacional y la satisfacción con las ocupaciones diarias representan dos conceptos centrales en la ciencia ocupacional. Partiendo de esta centralidad, el objetivo del presente estudio se dirigió a analizar las asociaciones entre diferentes aspectos del equilibrio ocupacional y la satisfacción con las ocupaciones diarias. Un segundo objetivo supuso examinar si los diferentes aspectos del equilibrio ocupacional pueden predecir la satisfacción con las ocupaciones diarias 12 meses después. Métodos: El presente estudio empleó un diseño de estudio piloto exploratorio longitudinal y formó parte de un proyecto en el que se evaluó el Método del Árbol para pacientes con depresión y/o trastornos de ansiedad. En el estudio se utilizaron datos recogidos directamente después de la intervención (n=107) y 12 meses después (n=84). Además, se usaron el Cuestionario de Equilibrio Ocupacional (OBQ) y el de Satisfacción con las Ocupaciones Diarias (SDO), empleándose regresiones logísticas binarias para analizar las asociaciones entre ellos. Resultados: Se encontraron asociaciones estadísticamente significativas entre los siguientes aspectos del equilibrio ocupacional: equilibrio entre el trabajo, el hogar, la familia, el ocio, el descanso y el sueño; no tener ni mucho ni poco que hacer durante una semana normal; satisfacción con el tiempo dedicado al descanso, la recuperación y el sueño y satisfacción con las ocupaciones diarias directamente después de la intervención. El elemento de equilibrio ocupacional, equilibrio entre las ocupaciones que dan energía y las que la consumen directamente después de la intervención, predijo la satisfacción con las ocupaciones diarias 12 meses después. Conclusión: Este estudio proporciona cierto apoyo a la hipótesis de que existe una asociación entre el equilibrio ocupacional y la satisfacción con las ocupaciones diarias. Por ello se recomienda realizar estudios con tamaños de muestra más grandes y en otras culturas, que permitan confirmar la presencia de estas asociaciones y/o encontrar otras asociaciones.

RÉSUMÉ

Introduction : L’équilibre occupationnel et la satisfaction à l’égard des occupations quotidiennes sont deux concepts centraux des sciences de l'occupation. Le but de la présente étude visait donc à explorer les associations entre différents aspects de l’équilibre occupationnel et de la satisfaction à l’égard des occupations quotidiennes. Un second but était d'explorer la possibilité que différents aspects de l’équilibre occupationnel aient prédit la satisfaction à l’égard des occupations quotidiennes 12 mois plus tard. Méthodes : Avec un devis d’étude pilote exploratoire corrélationnelle et longitudinale, la présente étude faisait partie d'un projet évaluant la méthode du thème de l'arbre (Tree Theme Method) appliquée aux patients vivant avec une dépression et/ou des troubles anxieux. Les données recueillies directement après l'intervention (n=107) et 12 mois plus tard (n=84) ont servi à la présente étude. Les questionnaires de l’équilibre occupationnel (Occupational Balance Questionnaire, OBQ) et de la satisfaction à l’égard des occupations quotidiennes (Satisfaction with Daily Occupations, SDO) ont été utilisés, puis des régressions logistiques binaires ont été utilisées pour explorer les associations entre les deux. Résultats : Des associations statistiquement significatives ont été trouvées entre les aspects suivants de l’équilibre occupationnel : Équilibre entre le travail, le domicile, la famille, les loisirs, le repos et le sommeil ; Ne pas avoir trop ni trop peu à faire durant une semaine normale ; Satisfaction à l’égard du temps de repos, de récupération et de sommeil et satisfaction à l’égard des occupations quotidiennes juste après l'intervention. L’élément d’équilibre occupationnel Équilibre entre les occupations énergisantes et énergivores directement après l'intervention a prédit la satisfaction à l’égard des occupations quotidiennes 12 mois plus tard. Conclusion : Cette étude apporte un certain appui à l'hypothèse d'une association entre l’équilibre occupationnel et la satisfaction à l’égard des occupations quotidiennes. Il est recommandé de mener des études avec des échantillons de plus grande taille et dans d'autres cultures pour confirmer la présence de ces associations et/ou en trouver d'autres.

KEYWORDS:

• Occupational science
• Anxiety
• Depression
• Occupational Balance Questionnaire
• Satisfaction with Daily Occupations Questionnaire

MOTS-CLÉS:

• Sciences de l'occupation
• Anxiété
• Dépression
• Occupational Balance Questionnaire (Questionnaire de l’équilibre occupationnel)
• Satisfaction with Daily Occupations Questionnaire (Questionnaire de la satisfaction à l’égard des occupations quotidiennes)

Occupational science is “the study of the human as an occupational being including the need for and capacity to engage in and orchestrate daily occupations in an environment over the life span” (Yerxa et al., 1989, p. 6). Occupation is multifaceted and in occupational science the experiences and factors pertaining to human occupation are studied (Christiansen & Townsend, 2014). The social, institutional, cultural, and social context as well as the person’s abilities and resources affect occupational engagement (Townsend & Polatajko, 2007), and thus satisfaction with daily occupations and occupational balance (Eklund et al., 2017). In the present study, the focus is on the interaction between the latter two.

It was found in a previous qualitative study (Håkansson et al., 2006) that when women with stress-related disorders experienced occupational balance they also experienced satisfaction with their daily occupations. Furthermore, an assumption in the life-balance model is that occupational balance requires a satisfying pattern of daily occupations (Matuska, 2012). An occupational pattern is the organisation of everyday occupations in time (Erlandsson & Eklund, 2001) and the composition of the occupational pattern is important for the experience of occupational balance (Eklund et al., 2009). Also, in a previous literature review by Eklund et al. (2017), it seemed as if occupational balance and the pattern of daily occupations interact. Both these concepts have been shown to be associated with health and well-being (Björklund et al., 2015; Håkansson et al., 2021; Orban et al., 2012; Wagman & Håkansson, 2014a), which makes them important in occupational science. It is therefore important to investigate whether there is an association between occupational balance and satisfaction with daily occupations in order to contribute to the body of knowledge in occupational science.

Occupational balance was defined as the individual’s perception of having the right amount of occupations and the right variation between occupations (Wagman et al., 2012), and satisfaction with daily occupations was defined as an overall contentment with the current engagement, or absence of engagement, in different daily occupations, such as work, leisure, home maintenance, and self-care (Eklund & Gunnarsson, 2007; Townsend & Polatajko, 2007).

Occupational balance was studied from the time use perspective by Eklund et al. (2010), who explored the relationship between time use and satisfaction with daily occupations among people with mental illness. Their results showed a relationship between these two, where the participants who spent more time in non-rest occupations were more satisfied with their daily occupations. However, less is known about the interaction between satisfaction with daily occupations and the two other perspectives of occupational balance (in relation to occupational areas and in relation to occupations with different characteristics) that also were identified in a concept analysis of occupational balance (Wagman et al., 2012).

To the best of our knowledge, no previous studies have fully investigated the association between occupational balance and satisfaction with daily occupations. The aim of the present study was therefore to explore associations between different aspects of occupational balance and satisfaction with daily occupations. A second aim was to explore whether different aspects of occupational balance predicted satisfaction with daily occupations.

Methods

The present study had an exploratory correlational longitudinal pilot study design and was part of a project in which the Tree Theme Method (TTM) was evaluated for patients with depression and/or anxiety disorders. The project is a randomized controlled clinical trial (NCT01980381) and the patients were randomized to the TTM (intervention group) or regular occupational therapy (control group).

Interventions and data collection

Patients in both interventions completed five sessions of 60 minutes each during a period of 6–9 weeks. The TTM starts each session with relaxation, and then the patient paints a tree representing a specific period of life: the present, childhood, adolescence, and adulthood. Based on the paintings the patient tells their occupational life story. At the end of each session, the patient and the occupational therapist have a reflective dialogue about necessary changes in the patient’s everyday life. Between the sessions, the patient works with these changes in everyday life. In the last session, the focus is on story making and on shaping plans for the future. The regular occupational therapy consisted of dialogue, sometimes in combination with activities, regarding the patient’s well-being and their current occupations in everyday life. Patients could be assigned tasks between sessions also in this treatment. In the present study, all participants were treated as one group.

Occupational therapists specifically trained in this data collection, but who were not involved in the intervention, met the participants and collected data. The participants could choose the place for data collection, and mostly they chose their regular primary health care center or outpatient mental healthcare unit. Data were collected on four occasions; prior to the treatment (T1), directly after the treatment (T2), and 3 (T3) and 12 months later (T4) (Gunnarsson et al., 2015). Data from directly after (T2) and 12 months after (T4) the intervention were used in the present study. These two occasions were chosen because T2 was directly after the intervention and the participants had increased their occupational balance and satisfaction with daily occupations (Gunnarsson et al., 2018) and T4 was 12 months after treatment, thus allowing the detection of any long-term effect of occupational balance on satisfaction with daily occupations.

Participants

The participants were recruited from primary health care and outpatient mental healthcare units in Southern Sweden. Men and women diagnosed with anxiety and/or depression, aged 18-65 were asked about how their illness affects their daily occupations by occupational therapists. Those whose daily occupations were affected, were asked about participation in the study. Exclusion criteria were severe somatic illness, psychosis, and/or difficulties in completing questionnaires due to lack of skills in understanding Swedish. A total of 118 were recruited at baseline, 107 of them completed the questionnaire directly after the intervention, and 84 a year later. The group was selected for the present study as it was considered pertinent, as the participants improved their occupational balance and satisfaction with daily occupations between the measurement occasions.

In accordance with the Declaration of Helsinki, all participants were informed that this study was voluntary, and that data would be handled confidentially. All participants gave their informed written consent. The Ethical Review Board in Linköping, Sweden approved the study (2012/232-31 and 2015/12-32).

Measurements

Occupational balance was measured with the original 13 items in the Occupational Balance Questionnaire (OBQ) (Wagman & Håkansson, 2014b). The level of agreement is rated on six ordered response categories with verbal descriptions, ranging from completely disagree [0] to completely agree [5]. The higher the score, the higher the level of occupational balance. The OBQ (Håkansson et al., 2020; Wagman & Håkansson, 2014b) includes the perception of the three perspectives of occupational balance (occupational areas, occupations with different characteristics, and time use). A revised version with 11 items was subsequently constructed (OBQ11) (Håkansson et al., 2020) and the analysis in the present study was performed on these 11 items (Table 1). The number of responses per response category was limited, thus the response categories were dichotomized according to the median into low occupational balance vs. high occupational balance for each item and the dichotomised responses were used in the analyses. The OBQ11 has shown to have acceptable construct validity (Rasch analysis) and good reliability (PSI 0.92) (Håkansson et al., 2020). Test-retest reliability of individual items varied from good to very good (Weighted kappa between 0.61- 0.83) (Wagman & Håkansson, 2014b).

Table 1: The OBQ Items (short form)

Item
Having neither too much nor too little to do during a regular week
Balance between doing things for others and for oneself
Time for doing things wanted
Balance between work, home, family, leisure, rest, and sleep
Having sufficient time for doing obligatory occupations
Balance between physical, social, mental, and restful occupations
Satisfaction with how time is spent in everyday life
Satisfaction with the number of occupations during a regular week
Balance between obligatory and voluntary occupations
Balance between energy-giving and energy-taking occupations
Satisfaction with time spent in rest, recovery, and sleep

Satisfaction with daily occupations was measured with the Satisfaction with Daily Occupations (SDO-13) (Eklund et al., 2014). This is an interview-based instrument that includes 13 items pertaining to work/studies, leisure, home maintenance, and self-care occupations. The participants rate their satisfaction with the occupations regardless of whether they perform the specific occupation or not. The SDO-13 has seven response categories, ranging from extremely dissatisfied [1] to extremely satisfied [7]. The ratings are summed to a total score, from 13-91, and the higher the score the higher the level of satisfaction with daily occupations. The sum score was dichotomized according to a median cut in the present study. The SDO-13 has shown satisfactory internal consistency (Cronbach Alpha 0.79) and no floor or ceiling effects have been detected (Eklund et al., 2014). Furthermore, sociodemographic factors, that is age, gender, number of children (none vs. 1-6 children), living with someone (yes vs. no), and educational level (university vs. other education) were included.

Statistical analysis

Frequencies and percentages were used to describe the characteristics of the participants. The present study was explorative and there was thus no theory guiding which independent variables to be entered in the regression model, or in which order. Therefore, binary logistic regression analyses with backward elimination were used to investigate associations between occupational balance and satisfaction with daily occupations, and to identify occupational balance predictors of satisfaction with daily occupations. The initial model in such analyses contains all independent variables (occupational balance and sociodemographic factors), and in the next step the independent variable with the highest p-value is removed and the model is re-run. This process is repeated until the model comprises only statistically significant independent variables (p<0.05) (Heinze et al., 2018). Prior to the addition of the occupational balance items to the initial model, potential multicollinearity was assessed by investigating correlations between them and the correlation coefficients were not too high (<0.7). Data are presented as odds ratios (ORs) with their 95%-confidence intervals (CIs). All statistical analysis was performed using the SPSS version 26.0 software.

Results

Most of the participants were women, lived with someone, but had no children. The great majority had a 9-year or high school education. The participants were 19-64 years old, with a median age of 42 years (Table 2).

Table 2: Characteristics of the Study Participants at Baseline (n=118)

	n (%)
Gender Woman Man	98 (83) 20 (17)
Children No child One or more children	77 (65) 41 (35)
Living with someone Yes No	75 (64) 43 (36)
Educational level University Other education	35 (30) 83 (70)

Associations between occupational balance and satisfaction with daily occupations directly after the intervention

The results showed that the participants who experienced high Balance between work, home, family, leisure, rest, and sleep had four times higher possibility to rate high satisfaction with daily occupations than the participants who experienced low balance between these occupations. The participants who experienced that they Have neither too much nor too little to do during a regular week and Satisfaction with time spent in rest, recovery, and sleep had about three times higher possibility of rating high satisfaction with daily occupations than the others. None of the sociodemographic factors were significant in this model (Table 3).

Table 3: Associations between Different Aspects of Occupational Balance and Occupational Satisfaction Directly after the Intervention¹ (n=107)

	OR (95% CI)
Balance between work, home, family, leisure, rest, and sleep	4.23 (1.57-11.45)
Having neither too much nor too little to do during a regular week	3.20 (1.23-8.37)
Satisfaction with time spent in rest, recovery, and sleep	2.93 (1.05-8.19)

¹ Backward elimination and in the first step were the 11 occupational balance items and the sociodemographic factors i.e., age, gender, number of children, living with someone, and educational level added.

Occupational balance directly after the intervention predicted satisfaction with daily occupations 12 months later

High Balance between energy-giving/energy-taking occupations directly after the intervention predicted satisfaction with daily occupations 12 months later, and the participants who experienced high balance between energy-giving/energy-taking occupations rated their satisfaction with daily occupations three times higher than the participants who experienced low balance between these occupations. None of the sociodemographic factors were significant in this model (Table 4).

Table 4: Different Aspects of Occupational Balance Directly after the Intervention as Predictors of Occupational Satisfaction 12 Months Later¹ (n=82)

	OR (95% CI)
Balance between energy-giving/energy-taking occupations	3.00 (1.11-8.14)

¹ Backward elimination and in the first step were the 11 occupational balance items and the sociodemographic factors i.e., age, gender, number of children, living with someone, and educational level added.

Discussion

The results of the present study showed associations between different aspects of occupational balance and satisfaction with daily occupations, which is in line with the assumption, in the life balance model (Matuska, 2012) and in the literature review by Eklund et al. (2017), that there is an association between these two. Based on the results of the present study, some aspects of occupational balance seemed to be strong indicators of satisfaction with daily occupations.

Cross-sectional associations were found between the occupational balance items Balance between work, home, family, leisure, rest, and sleep, Having neither too much nor too little to do during a regular week and being Satisfied with the time for rest, recovery, and sleep and satisfaction with daily occupations. The occupational balance item Balance between energy-giving and energy-taking occupations after the intervention predicted satisfaction with daily occupations 12 months later. Each of the items above indicates that what is most important is to engage in a variety of occupations, but not in greater amount than the individual has resources to handle. The OBQ focuses on satisfaction with the amount and variation of occupations, regardless of what they are. The SDO focuses on satisfaction with the daily occupations. Both are subjective experiences of one’s occupational pattern. If the individual experiences occupational balance, it seems reasonable that he or she experiences satisfaction with daily occupations (total score). In this way the results of the present study strengthen the assumption that occupational balance and satisfaction with daily occupations interact. Furthermore, the results showed that high Balance between energy-giving and energy-taking occupations had a long-term effect on satisfaction with daily occupations. This can be interpreted as high Balance between energy-giving and energy-taking occupations being the most important predictor of satisfaction with daily occupations for this group, but further studies in other groups are warranted. However, the reverse may also be true, that is, that satisfaction with daily occupations predict occupational balance.

The total score of satisfaction with daily occupations (subjective aspect) reflects how satisfied the individual is with his or her occupational pattern (objective aspect). A previous study showed that this objective time use aspect and occupational balance were related (Eklund et al., 2010). However, the results of the present study showed that the time use perspective of occupational balance did not predict satisfaction with daily occupations. This result can be interpreted as if the time distribution between different occupations and overall time use are less important than the variation between different occupations. Perspectives of time use and occupational balance were focused on in another study and the authors found that awareness of time use was important for occupational balance (Pemberton & Cox, 2014). Their results can contribute to an interpretation of the result of the present study in terms of an awareness of the time distribution between occupations being important. A review by Eklund et al. (2017) showed that occupational balance and occupational pattern are linked. The occupational pattern shows how time is used and a prerequisite for experiencing sufficient occupational balance can be an awareness of what the occupational pattern looks like, how time and energy are used, and in which occupations energy is replenished. It appears to be important to combine the mapping of occupational balance with a mapping of occupational pattern, as a satisfying occupational pattern (satisfaction with the organisation of occupations in time) is a prerequisite for occupational balance (Matuska, 2012). Furthermore, changes in a person’s occupational pattern will affect his or her satisfaction with daily occupations and thus also the experience of occupational balance.

Sociodemographic factors were included in the logistic regression analysis in the present study. However, none of them was statistically significant. As in the present study, no associations were found in the study by Argentzell et al. (2012) between gender, civil status, educational level, children, and satisfaction with daily occupations. A study of the same sample as in the present study showed that there was no difference in the level of occupational balance between participants with different demographic characteristics (Wagman et al., 2019). The results indicated that occupational balance is multifaceted and that a combination of various aspects is associated with satisfaction with daily occupations. Furthermore, the results indicate which aspects of occupational balance are important and change over time, while it is important that the amount and variation is correct in relation to the individual’s abilities and resources. Furthermore, by the associations found between occupational balance and satisfaction with daily occupations, a step is taken towards linking occupational science concepts, which has been proposed as an important feature in the development of a scientific area (Kaplan, 1998).

Limitations

All participants in the present study had depression and/or anxiety disorders. Recruitment from other diagnostic groups may have yielded other results and further studies are needed. The groups with high/low levels of satisfaction with daily occupations were rather small. Due to this, the confidence intervals were rather wide, and the results therefore should be interpreted with some caution.

Conclusion

This study provides some support for the assumption that there is an association between occupational balance and satisfaction with daily occupations. Furthermore, it provides support that these are important concepts in occupational science and research. However, these concepts have to be further validated in empirical research that more extensively investigates and establishes the association between occupational balance and satisfaction with daily occupations. Studies with larger sample sizes and in other cultures are recommended to confirm the presence of these associations and/or to find other associations. Furthermore, studies of the associations between different aspects of occupational balance and satisfaction with the individual occupations would also be of interest.

Declaration of Interest

The authors report no conflicts of interest.

Acknowledgement

Thanks to all participants in the present study and to the research assistants who collected the data.