https://orcid.org/0000-0003-0467-4857
Abstract
Background
It is well known that engagement in occupations becomes restricted after acquired brain injury (ABI), but little is known about how this influences occupational values and occupational balance.
Aim
To describe the extent to which persons with ABI perceived occupational value; to explore whether occupational value and occupational balance were associated with life satisfaction, and to explore how occupational value, occupational balance, the severity of disability, fatigue and sociodemographic characteristics influenced life satisfaction.
Materials and methods
A cross-sectional study was undertaken with 75 participants of working age with ABI who responded to questionnaires on occupational value, occupational balance, and life satisfaction. Additionally, instruments covering fatigue and severity of disability were administered. Data were analyzed by means of comparisons, correlations and logistic regression.
Results
A high perceived occupational value and a high perceived occupational balance were significantly associated with satisfaction with life as a whole, psychological health and somatic health. The logistic regression showed that occupational value, occupational balance and severity of disability significantly impacted satisfaction with life as a whole.
Conclusions and significance: Occupational value and occupational balance together with severity of disability, are important areas of focus in the later phase of rehabilitation after ABI to promote satisfaction with life as a whole.
In occupational therapy it is assumed that engagement in occupations is a source of meaning in our lives [Citation1–5] and is related to experiences of health [Citation4,Citation6]. Occupation is described as a complex phenomenon and a subjective event, i.e. a personally constructed experience within a specific context [Citation7], and, therefore, people may define and experience an occupation differently [Citation3]. For an occupation to be perceived as meaningful, it is argued that it must possess value for the person. Occupational value is described as a dynamic construct, generating a sense of meaning that is expected to be important for health [Citation3].
Occupational value comprises three dimensions: concrete, symbolic and self-rewarded values that represent related yet distinct paths to understanding occupation, value and meaning [Citation3]. Empirical research has confirmed that occupational value has a clear relationship with perceived meaning [Citation8] and is related to subjective health [Citation8–10]. As different occupational values are part of everything people do and engage in within everyday life, it can be assumed that people need a mix of values to support a sense of meaning and to experience health. A concept closely connected with occupational value and health is occupational balance, i.e. a subjective experience of having the right variation and amount of occupations [Citation11]. Thus, it is important to map out not only the occupations that people engage in but also the value of these occupations and its relationship with perceived occupational balance and health.
After acquired brain injury (ABI), engagement in meaningful occupations often becomes restricted. Although the severity of disability varies after ABI, many of those of working age experience activity limitations and participation restrictions [Citation12–14]. Their engagement in occupations becomes more or less limited to activities that need to be performed to function in everyday life [Citation15]. Furthermore, engagement in activities outside the home, such as social and leisure activities, often becomes challenging, and as a result, people with ABI visit fewer places and perform more of their activities at home and alone [Citation15–17]. This implies that perceived occupational value and occupational balance can vary.
Research has shown that being able to engage in desired everyday activities is strongly correlated with health in terms of life satisfaction after ABI [Citation18]. However, there is a lack of knowledge on how different occupational values are influenced after ABI, if there is a blend of different occupational values, if some occupational values are lacking and whether occupational values are replaced. Recent research shows that the perceived occupational balance becomes disrupted after stroke [Citation19]. However, there is no knowledge of how occupational value is related to perceived occupational balance and how this relates to life satisfaction. Furthermore, it is well known that sociodemographic characteristics and factors related to the injury e.g. the severity of disability influence occupations and life satisfaction after ABI [Citation18,Citation20–22]. Therefore, it is important to determine whether occupational value and occupational balance add to the understanding of important factors for life satisfaction after ABI. Such knowledge can improve the design of interventions to support people to continue or recapture engagement in meaningful occupations promoting health and life satisfaction. Therefore, the aims of this study were as follows: (i) to describe the extent to which persons with ABI perceived occupational value; (ii) to explore whether occupational value and occupational balance were associated with satisfaction with life as whole and psychological and somatic health; and (iii) to explore how occupational value, occupational balance, the severity of disability, fatigue and sociodemographic characteristics influenced the likelihood of satisfaction with life as whole.
Method
Design and participants
An explorative cross-sectional study was conducted using standardized assessments. The study was approved by the ethics committee of Umeå University, Sweden (Dnr. 2016-169-32). A total sampling was used, and potential participants were recruited from a database of a hospital in northern Sweden. The inclusion criteria were: (i) acquired brain injury, (ii) age 18–64 years, (iii) 12 to 84 months since diagnosis and (iv) residence in one of four municipalities located near the hospital. Before enrolment, 178 potential participants received written information about the study and its purpose, the content of participation, confidentiality and their right to withdraw at any time. Those who responded were contacted by phone and provided verbal information before giving their final informed consent. In total, 75 participants gave their written informed consent to participate, while 72 declined participation and 31 could not be reached by phone or e-mail. A comparison between the participants and nonparticipants showed no significant differences (p < 0.05) according to sex (Chi2), age and months since injury (t-test).
Instrument and data collection
The Occupational Value Assessment with predefined items (OVal-pd) [Citation9,Citation23] was used to assess the overall perception of occupational value and how frequently a certain type of occupational value appeared in the person’s life during the past month. The OVal-pd consists of 18 items reflecting the three dimensions of occupational values: six items reflecting concrete value, four items reflecting symbolic value and eight items reflecting self-rewarded value. The items are rated on a four-point ordinal scale with the following response options scored 1–4, respectively: not at all, rather seldom, rather often and very often. A higher score indicates that the respondent is frequently engaged in valued occupation. The rating of the OVal-pd can be summed into a general occupational value (ranging between 18 and 72) and for the three different dimensions of occupational value. Evaluation of the psychometric properties of the Oval-pd [Citation23] showed that the instrument measures occupational value in a reliable and valid way. The Occupational Balance Questionnaire (OBQ) [Citation24] assesses perceptions of having the right amount and variation of occupations in daily life with 13 items. The items are rated on a four-point ordinal scale scored 0-3 respectively: strongly disagree, disagree, agree, and strongly agree. The ratings of the OBQ are summed as the total score (ranging between 0 and 39). A higher score implies more satisfaction with the amount and variation of occupations, i.e. a higher level of occupational balance. The validity and reliability of the OBQ has been confirmed [Citation24,Citation25]. From the Life Satisfaction Questionnaire (LiSat-11) [Citation26,Citation27], three items, namely, satisfaction with life as whole, somatic health and psychological health, were assessed via self- report on a six-point scale ranging from very dissatisfied (1) to very satisfied (6). Reports are classified as not satisfied/dissatisfied for scores ranging from 1 to 4 and satisfied for 5 or 6. The scale has been found to be reliable and valid. The standardized interview-based instrument Glasgow Outcome Scale-Extended (GOSE) [Citation28] was used to measure the severity of disability (including independence in daily life and return to work and former life activities). The Swedish version of Fatigue Severity Scale (FSS) was used to assess the prevalence of self-reported fatigue [Citation29,Citation30].
Data collection was performed by personal meetings that took place mainly in the participant’ homes but also at other places (data collectors’ workplace or at a rehabilitation unit), depending on each participant’s preference. The data collection was conducted by two registered occupational therapists and researchers, both experienced in interviewing persons with brain injuries. To ensure the completeness and quality of data with respect to a participant’s daily condition, data were collected on one or two occasions. The data collection started with questions about the participants’ sociodemographic variables () and continued with the FSS, OVal-pd, OBQ, LiSat-11 and GOSE. Detailed results of all items from the OBQ for parts of participants with stroke have been published elsewhere [Citation19].
Table 1. Characteristics of persons with acquired brain injury (ABI) (n: 75).
Data analysis
Descriptive statics were used to identify the participants’ sociodemographic characteristics, perceived occupational value and occupational balance. Test results were given in absolute and relative frequencies as well as in means with SDs, depending on appropriateness. In preparation for the forthcoming analysis, the summed (total) perceived occupational value (OVal-pd) and occupational balance (OBQ) were calculated for each participant. Additionally, the summed values for the three dimensions of occupational value were calculated [Citation8]. The responses on the three items of the LiSat-11 (satisfaction with life as whole, psychological health and somatic health) were grouped as satisfied and not satisfied [Citation21]. Then Spearman rank-order correlation analysis was performed among the three items from the LiSat- 11 and the three dimensions of occupational value. Then a comparison, using the Mann–Whitney U test, was performed between the groups being dissatisfied or satisfied with each of the three items from the LiSat- 11, and the summed perceived occupational value and summed occupational balance, and explored with descriptive statistics. Thereafter, a series of logistic regressions including both univariate and multivariate analyses were performed to explore how the independent variables (sex, age, marital status, educational level, severity of disability, fatigue, occupational value and occupational balance) contributed to the likelihood of satisfaction with life as a whole. Initially, univariate analysis was conducted with all independent variables, and those that were significant were included in the multivariate analysis. The significance level for all tests was set at p < 0.05, and all statistical analyses were performed using SPSS 26.0 (SPSS Inc., Chicago, IL).
Results
The sample included almost as many women as men, and their mean age was nearly 53 years. The majority of the participants had moderate or severe disability and suffered from fatigue (). Thirteen out of the eighteen investigated occupational values had been perceived ‘often’ or ‘very often’ over the past month by the majority of the sample (). The five occupational values that a majority of the participants perceived ‘not at all’ or ‘rather seldom’ were related to symbolic or self-rewarded values (marked in Italic, ). All three dimensions of occupational value (concrete, symbolic and self-reward value) were positively correlated with aspects of life satisfaction ().
Table 2. Aspects of occupational value in a sample of people of working age with acquired brain injury assessed by the occupational value instrument with predefined items (OVal-pd) (n:75).
Table 3. Dimensions of occupational values and associations with life satisfaction in people of working age with acquired brain injury (n: 75).
A high perceived occupational value and a high perceived occupational balance were significantly associated with satisfaction with life as a whole, psychological health and somatic health (). The logistic regressions () showed that perceived occupational value, perceived occupational balance and severity of disability significantly influenced satisfaction with life as a whole in the univariate analyses. Additionally, these occupational-related variables continued to significantly influence satisfaction with life as a whole in the multivariate analysis. Sociodemographic characteristics and fatigue did not significantly contribute to satisfaction with life as whole in the sample. Having a high perceived occupational value and a high perceived occupational balance as well as good recovery (less remaining disability), contributed to a higher probability of perceiving satisfaction with life as a whole.
Table 4. Life satisfaction versus occupational balance and occupational value in sample of people of working age with acquired brain injury (n: 75).
Table 5. Univariate and multiple logistic regression of variables associated with satisfaction with life as whole in a sample of people of working age with acquired brain injury (n: 75).
Discussion
The results showed that all/only occupation variables (occupational value, occupational balance and disability severity) significantly impacted the participants’ satisfaction with life as a whole. However, neither fatigue nor any of the sociodemographic variables had a significant impact. This indicates that to engage in a variety of occupations, it is important to focus on rehabilitation in the later phase of an ABI to promote satisfaction with life as a whole. More specifically, the results indicate the importance of not only focussing on performance and independence in occupations in daily life (disability severity) but also on perceived occupational values and balance. Occupational therapists and other rehabilitation professionals need to focus on the extent to which clients perceive different dimensions of occupational values and, if they have the right amount and a varied mix of occupations. Consequently, the whole pattern of occupations needs to be considered, in contrast to the approach of current rehabilitation services, in which goal setting commonly focuses on independence or improved engagement in some defined (often single) occupation of daily life, with the aim of performing this activity more efficiently, more independently or with less effort [Citation31,Citation32]. Consequently, with such an approach there is a risk that a broader perspective on the whole occupational pattern, in accordance with occupational therapy theory [Citation3,Citation8,Citation33,Citation34] is overlooked, i.e. a mix and variations of occupations to support health. However, the results need to be considered in light of potential biases related to the small sample size and the cross-sectional design, implying that causality cannot be inferred. Moreover, as more than one year had passed since the injury for the participants, it is important to note that the discussed implications of the study concern the later phase of the rehabilitation. Hence, research is needed to clarify whether similar associations can be found at an earlier stage, indicating a shift towards a broader focus on the early phase of rehabilitation.
The results of the comparisons between the groups that were satisfied or dissatisfied with life as whole and psychological and somatic health showed that the (general) perceived occupational value and occupational balance were significantly lower in those who were dissatisfied. Consequently, a limited extent of occupational values, a low occupational balance and dependence in activities of daily living were significantly associated with dissatisfaction with life as a whole. In the univariate analysis, neither fatigue nor any of the sociodemographic variables had a significant impact on satisfaction with life as a whole. This is somewhat surprising as previous research in a Swedish normal population [Citation26,Citation27] and people with ABI [Citation18,Citation20–Citation22] has shown that socio-demographic and injury-related factors significantly influence life satisfaction. However, the fact that fatigue and sociodemographic did not have an impact might be explained by the small study sample. Therefore, further research including a larger sample is needed to verify the results.
The occupational values that a majority of the participants perceived not at all or seldom were related to self-rewarding and symbolic values. These values are related to occupations that bring joy, pleasure and immediate reward. Further, values that represent a symbolic value for the person and for the socio-cultural context that support identity and cultural belonging. This might indicate that occupations involving these values were lost or that too much effort was put into achieving the concrete value i.e. occupations with an actual beginning and end as well as a concreate result, thus, diminishing the other values in an occupation. These results should be viewed in light of previous research in other groups, which has shown that self-rewarding values in particular are linked to meaning and experiences of health [Citation8,Citation9]. Interestingly, two out of four items representing symbolic value were perceived as low. This might indicate, in line with previous research [Citation16,Citation17] that engagement in socio-cultural occupations becomes restricted, such as occupations with others in public space. The results also showed that all three dimensions of values were of significant importance for somatic health, psychological health and life as a whole. Notably, concrete value had the strongest correlation with all three LiSat-11 items, whereas self-rewarding values had the lowest correlation (even if it was moderate). This indicates, in accordance with previous research [Citation8,Citation35], that all dimensions of occupational values are important for life satisfaction and subjective health. Consequently, a loss of values can pose the risk of reduced life satisfaction and poorer health. Therefore, occupational therapy service needs to support clients to increase their awareness of the values connected to different occupations. Further, support clients to develop strategies to regain important values in occupations, thus facilitating meaning in life. To support clinical practice, further studies are needed to explore how values change and influence meaning for people with ABI.
The result indicates the need of developing lifestyle interventions empowering engagement in activities in everyday life in later phases after ABI. Results show that occupations at all levels i.e. micro, meso and macro perspective, in accordance with theory [Citation34], is important for the experience of satisfaction of life as a whole. In this sense, the results suggest that occupational therapy interventions need to consider not only the performance of occupations but also the daily and weekly patterns of occupation and how values and meaning are generated from a life-time perspective (cf. [Citation34]). By supporting clients to become aware of the occupations they do, how they perform them, the meaning generated from them and how they are organized over time in relationship to each other, they will be better prepared to self-manage changes in everyday life after ABI. Therefore, we suggest that the persons whole pattern of occupation should be at the centre when deciding on long-term goals for the rehabilitation. Here, the assessments used in this study, Oval-Pd [Citation9,Citation23] and OBQ [Citation24,Citation25], could be used as a resource together with an activity diary. Whereas, evaluation of isolated occupations and aspects of them are steps to achieve the long-term goals. Similarly, the results suggest that future research of factors influencing life satisfaction and health also needs to include occupation variables related to micro, meso and macro levels. Thus, it is not sufficient to only include occupation variables on e.g. the micro level such as occupational performance to fully understand the impact of occupation on satisfaction with life as a whole and health.
Methodological considerations
To our knowledge, this is the first study to focus on relationships among occupational value, occupational balance and life satisfaction after ABI. Therefore, the results can be considered a first step to understanding how a greater complexity of occupations is related to health and life satisfaction in people with ABI. The sample was rather small, and there were few participants in some of the sociodemographic categories, indicating that the results can be affected by bias. When the participants were divided into two groups (satisfied and dissatisfied), for the three items on the LiSat- 11, the potential for bias increased even more. The selection of only some variables from the life satisfaction questionnaire can be discussed. However, in research, life satisfaction is often assessed by only using ‘satisfaction with life as whole’. Research [Citation35] has also shown that it can be seen as a global item, as it is associated with almost all other domain-specific items included in the questionnaire. Further studies are needed with larger samples from each ABI group to validate the findings of this study.
Conclusion
The results demonstrate the importance of focussing on performance and independence in daily life, together with occupational values and occupational balance, in the later phase of rehabilitation after ABI.
Significance
Rehabilitation in the later phase should focus on the extent to which persons with ABI perceive different dimensions of occupational values and the right amount and a varied mix of occupations. Consequently, the whole pattern of occupations needs to be considered to improve the promotion of life satisfaction in the later phase of ABI.
Acknowledgements
The authors want to thank all the participants who chose to participate in the study. Additionally, we thank Alexandra Olofsson, PhD, in occupational therapy; Luleå University of Technology for support with the data collection; and Robert Lundqvist, Region Norrbotten for support with the statistical analysis.
Disclosure statement
The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.
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