Occupational balance from the interpersonal perspective: A scoping review

ABSTRACT

Background: Occupational balance is an important concept in occupational science but it has mostly been studied from an individual rather than an interpersonal perspective, i.e. the extent to which one individual’s occupational balance affects and is affected by others. The aim of this review was to describe the extent to which occupational balance has been recently considered from an interpersonal perspective.

Methods: A scoping review methodology was used. Articles published between 2014 and 2017 that met the following inclusion criteria were included: full articles reporting primary research; published in English; using “occupational balance”, “balance in everyday life”, or “life balance” in the abstract, key words, or title; having an occupational focus on balance; and providing relevant information in relation to the interpersonal perspective.

Results: Nine articles were included. The interpersonal perspective was mostly seen in relation to partners or families, showing the positive impact of support and the negative impact of meeting other’s needs in mothers. One article addressed aspects related to organizations and attitudes at the workplace in parents with young children.

Conclusion: The findings reveal the importance of considering the occupational balance of both the individual and those around him or her while also showing some of the complexity of occupational balance. The limited number of articles identified indicates that there is still a lack of research using an interpersonal perspective, suggesting that further examination of the interpersonal influence on occupational balance may be a fruitful avenue to pursue.

背景：生活活动平衡是生活活动科学的一个重要概念，但它主要是从个人角度而不是从人际角度进行研究。人际角度是指一个人的生活活动平衡影响他人和受其他人影响的程度。本研究的目的是描述最近从人际角度考虑生活活动平衡的程度。

方法：使用细致审查方法。 所引用的2014年至2017年期间发表的文章符合以下纳入标准：报告初级研究的完整文章；以英文出版；在摘文、关键词或题目中使用“生活活动平衡”，“日常生活平衡”或“生活平衡”；从生活活动角度来着重探讨平衡；并提供关于人际关系的相关信息。

结果：共纳入9篇文章。人际关系视角主要与合作伙伴或家庭有关，显示出支持的积极影响以及母亲满足他人需求的负面影响。一篇文章探讨有幼儿的父母的工作单位的组织和态度方面的问题。

结论：研究结果揭示，考虑一个人及其周围人的生活活动平衡是很重要的，同时也显示了生活活动平衡的一些复杂性。所确定的文章数量有限，表明仍然缺乏从人际关系视角进行的研究，也表明进一步研究人际关系对生活活动平衡的影响可能会是一个富有成效的研究方向。

Antecedentes: Si bien la noción de equilibrio ocupacional constituye un concepto importante en la ciencia ocupacional, en la mayoría de los estudios sobre el tema es abordada desde una perspectiva más individual que interpersonal, es decir, hasta qué punto el equilibrio ocupacional de un solo individuo afecta a los demás y viceversa. La presente revisión se propuso examinar qué tanto el equilibrio ocupacional ha sido estudiado recientemente desde la perspectiva interpersonal.

Métodos: A fin de cumplir con este objetivo se utilizó una revisión de alcance. Para ello se consideraron artículos que cumplían con los siguientes criterios de inclusión: artículos completos de investigación primaria; publicados en inglés; que incluyeran las palabras “occupational balance”, “balance in everyday life”, o “life balance” en el resumen, las palabras clave o el título; tuvieran un enfoque ocupacional en el equilibrio; y proporcionaran información pertinente en relación con la perspectiva interpersonal.

Resultados: Fueron estudiados nueve artículos. La perspectiva interpersonal se abordó principalmente con respecto a parejas o familias, para mostrar el impacto positivo que conlleva el hecho de contar con respaldo y cómo las madres fueron impactadas negativamente al estar satisfaciendo las necesidades de los demás. Uno de los artículos trataba aspectos vinculados con las organizaciones y las actitudes en el lugar de trabajo de padres con hijos pequeños.

Conclusión: Los hallazgos dan cuenta de la importancia que reviste tomar en cuenta el equilibrio ocupacional tanto del individuo como de las personas que lo rodean; también revelan algo de la complejidad que encierra el balance ocupacional. El limitado número de artículos pertinentes indica que las investigaciones que utilizan la perspectiva interpersonal aún son escasas; ello sugiere que un camino prometedor puede ser el que futuros estudios analicen la influencia interpersonal en el equilibrio ocupacional.

KEYWORDS:

• Occupational science
• Health promotion
• Systematic review

View translated version:

Equilibrio ocupacional desde la perspectiva interpersonal: Una revisión de alcance

Occupational balance concerns the perception of having the ‘right mix’ of occupations in life (Wagman, Håkansson, & Björklund, 2012). It is an important concept in occupational science, of interest for almost a century (Meyer, 1922/1977). It was included in one of the first occupational science books (Christiansen, 1996) as well as researched at that time (Wilcock et al., 1997). Thereafter, it has been highlighted again over the years (e.g. Backman, 2004; Douglas, 2006; Eklund et al., 2017; Wagman, Håkansson, & Jonsson, 2015; Westhorp, 2003). Over recent decades, research regarding occupational balance has been conducted in general populations (Håkansson, Björkelund, & Eklund, 2011; Håkansson, Lissner, Björkelund, & Sonn, 2009; Wagman, Björklund, Håkansson, Jacobsson, & Falkmer, 2011; Wagman, Håkansson, Jacobsson, Falkmer, & Björklund, 2012) and in populations with a health condition (Bejerholm, 2010; Forhan & Backman, 2010; Håkansson & Matuska, 2010). The relationship between occupational balance and health and well-being has been found to be positive (Bejerholm, 2010; Forhan & Backman, 2010; Håkansson et al., 2011; Håkansson et al., 2009). Thus, occupational balance is important for health promotion.

Occupational balance has mostly been studied from an individual perspective (Wagman et al., 2015) with a focus on one individual’s occupational balance and its relation to the same individual’s health. While that is important, moving beyond the individual has been emphasized as important too (Dickie, Cutchin, & Humphry, 2006; Gerlach, Teachman, Laliberte-Rudman, Aldrich, & Huot, 2017; Laliberte Rudman, 2013). That concern is also relevant in relation to occupational balance, as one individuals’ occupations can impact on others, both negatively and positively, affecting whether or not they can achieve occupational balance (Wagman et al., 2015). For instance, it is possible to imagine a couple where occupational balance is enhanced in one of the partners by reducing the time spent doing household chores. If the chores are instead done by the other person, his or her occupational balance may be affected in a positive or negative direction, depending on how the change is perceived. Thus, another relevant perspective on occupational balance is the interpersonal perspective, i.e. the extent to which one individual’s occupational balance affects and is affected by other people. Adding an interpersonal perspective to occupational balance would provide more knowledge about the concept and about people’s occupations in a context, also contributing positively to the development of occupational science.

Solely using an individual perspective has previously been shown as a research gap in a scoping review aiming at “explore and describe current research about occupational balance and to identify research gaps in the existing literature” (Wagman et al., 2015, p. 161). That review included articles published between 2009 and early April 2014 but no knowledge exists about the extent to which the interpersonal perspective has been used in more recent research on occupational balance. The decision was therefore taken to conduct a new scoping review focusing on the interpersonal perspective in the intervening 4 years. The aim of this study was to describe the extent to which occupational balance has been considered from an interpersonal perspective.

Method

A scoping review methodology (Arksey & O’Malley, 2005) was considered relevant to map the information about the research related to the interpersonal perspective. It is a method suitable for examining “the extent, range and nature of research activity” (p. 21) and topics where various designs may be relevant to include. The study followed the five steps in the scoping review methodology (Arksey & O’Malley, 2005) and used published articles as data. In the first step, the research question “What has been written about occupational balance from an interpersonal perspective?” was developed. In the next step, relevant studies were identified by searching in databases and using their reference lists and citations. In line with the third step in the methodology (Arksey & O’Malley, 2005), the studies to be included were selected. It was decided that they should meet the following criteria:

• full articles reporting primary research

• published in 2014 or later in English

• use “occupational balance”, “balance in everyday life”, or “life balance” in the abstract, key words, or title and have an occupational focus on balance

• include an interpersonal perspective on occupational balance or provide relevant information in relation to the interpersonal perspective.

The AMED, CINAHL, and Medline databases were searched in November 2017 using the terms “occupational balance”, “balance in everyday life”, and “life balance NOT work/life balance”. The references and citations of the articles read were also checked for the potential inclusion of more articles. The process of data collection is shown in Figure 1.

Figure 1. Flowchart of the Process of Article Selection

Thereafter, in step four, the data were charted into a form including general and specific information (Arksey & O’Malley, 2005). This was used for presenting the review findings, including the first author and publication year, the number of participants, participants’ gender, and country the research was conducted in. The research design and the aim of the study were also included along with results contributing to knowledge from the interpersonal perspective (Table 1). In the fifth and final step, the findings were synthesized and described.

Table 1. The Articles Included.

First author, year	Participants,country	Method	Aim (main)	Contribution to knowledge about the interpersonal perspective of occupational balance
Borgh 2018	490 females 228 males Sweden	Cross-sectional	“Examine associations between organisational factors and occupational balance among parents with small children in Sweden” (p. 410).	There was an association between higher occupational balance and:  • Having someone at work to give work tasks to when workers need to be away • The perception that colleagues have a positive attitude towards parenthood.
Eklund 2016	226 (73% females) Sweden	Cross-sectional	“(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” (p. 304).	Participants with children had more occupationally imbalance by being over-occupied in domestic work and under-occupied regarding taking care of oneself.
Hodgetts 2014	139 males and 19 females Canada	Mixed methods	Examine “the impact of professional services on employment and leisure participation of mothers with children with autism” (p. 81).	Participating in therapy may take time from other occupations and decrease occupational balance.
Myers 2016	15 females USA	Qualitative	Investigate “the utility of the [Matuska’s life balance] model to explain perceptions of life balance of the Religious Sisters of Mercy” (p. 145).	Relationships that include “a mutual sense of caring” for each other are important for occupational balance.
Santoso 2015	14 females Indonesia	Constant comparison	“Identify and describe processes influencing resilience in the context of daily occupations among Indonesian mothers of a child with ASD [autism spectrum disorder]” (p. 2).	Describes how the degree of partner involvement and paid help affect occupational balance
Wada 2014	15 females 15 males Canada	Phenomeno-graphy	“Better understand how men and women in dual-income couples with at least one preschool-aged child conceive of balance in everyday life” (p. 259).	Balance implies meeting the needs of the family and sharing with one’s partner.
Wada 2015	15 males Canada	Phenomeno-graphy and critical discourse	“Contribute to advancing the conceptualization of balance among fathers by investigating how men in dual-income couples with young children construct balance in everyday life and by discussing the ideologies embedded in their discursive constructions of balance” (p. 120).	Occupational balance relates to both individual and collective needs in the family.
Yazdani 2016	5 females 5 males Iran	Qualitative	Expand “knowledge of occupational balance by exploring how it is understood by Iranian occupational therapy practitioners and academics” (p. 54).	Both family and community are important in relation to occupational balance. Occupational balance may be shared between family members.
Yazdani 2018	12 females 2 males UK	Qualitative	“Explore how the concept of occupational balance is perceived and practised by occupational therapy practitioners” (p. 289).	Principle of not causing harm to others is of importance in relation to occupational balance.

Results

Nine articles met the inclusion criteria (see Table 1). Their number of participants varied between 10 (Yazdani, Roberts, Yazdani, & Rassafiani, 2016) and 718 (Borgh, Eek, Wagman, & Håkansson, 2018). Most of the studies were conducted in Europe and North America.

Hodgetts, McConnell, Zwaigenbaum, and Nicholas (2014) most clearly used an interpersonal perspective when they conducted research involving mothers of children with autism, whose occupational balance was negatively affected by the treatments they undertook with their children. Four other studies used both individual and interpersonal perspectives; occupational therapists were the participants in two and parents were the participants in two. In one of the latter, Wada, Backman, Forwell, Roth, and Ponzetti (2014) had interviewed couples with children about occupational balance, and in another study, they used information solely from the fathers (Wada, Backman, & Forwell, 2015). In both studies, they found that balance includes meeting the needs of the family as well as sharing with one’s partner. The authors highlighted the interpersonal perspective as new, stating “this finding significantly extends the understanding of balance, as the concept is typically associated exclusively with a state of individual health and well-being” (Wada et al., 2014, p 272). In two other studies, Yazdani, Harb, Rassafiani, Nobakht, and Yazdani (2018) and Yazdani et al. (2016) researched perceptions of occupational balance held by occupational therapists in Iran and in the UK. From the perspective of the Iranian participants, occupational balance is something that can be shared among family members (Yazdani et al., 2016). The UK participants expressed their opinion that one individual’s occupational balance should not harm others. The authors concluded “therefore, the right occupational balance is not only about an individual’s own satisfaction, but it must also follow the principle of no harm to others” (Yazdani et al., 2018, p. 8).

Information relevant to the interpersonal perspective was also identified in articles that took an individual perspective. The content was related to the value of relationships for occupational balance (Myers et al., 2016), to the potential impact on occupational balance of having children (Eklund & Argentzell, 2016), and to the value of having supported relatives or finances to pay for help (Santoso, Ito, Ohshima, Hidaka, & Bontje, 2015). Moreover Borgh et al. (2018) researched occupational balance in relation to organizations and attitudes at the workplace among parents to small children. They found that those who experienced a positive attitude towards parenthood and parental leave in their work place, and those who had a structured way to hand over work when absent, had higher probability of reporting more satisfaction with their occupational balance. The authors concluded that their results “indicates that some organisational factors could be important for the occupational balance of parents with small children” (p. 409).

Discussion

The present study aimed to describe the extent to which occupational balance has been considered from an interpersonal perspective, i.e. where one individual’s occupational balance affects and is affected by others. Taken together, the few findings highlighted the importance of considering both individuals and the people around them.

The only one study (Hodgetts et al., 2014) with a solely interpersonal perspective on occupational balance had been included in the previous scoping review of research related to occupational balance, where it was highlighted as an exception to the predominantly individualistic perspective being reported (Wagman et al., 2015). Thus, it can be concluded that this research gap still exists. However, there were more articles including both an individual and interpersonal perspective, and, potentially, both perspectives should be included simultaneously. For instance, Wada et al. (2014) highlighted the interpersonal perspective in relation to health beyond the individual and warned that the individual perspective is insufficient for fully understanding the concept. The potential lack of occupational balance in caregivers has also been recognized, as well as the need for interventions to enhance their occupational balance (Hodgetts et al., 2014). The importance of this has been highlighted by others (McGuire, Crowe, Law, & VanLeit, 2004; Mthembu, Brown, Cupido, Razack, & Wassung, 2016).

Moreover, interviews with occupational therapists revealed perceptions about the possibility of sharing occupational balance across the family and also of the importance of not harming others (Yazdani et al., 2018; Yazdani et al., 2016). Further studies delving deeper into these perspectives, how widespread such views are and whether they vary in relation to different cultures, would be valuable. Not harming others might be related to the direct environment of occupational therapy clients, but might also be extended to a broader context of relevance for occupational science. Put very broadly, it can be extended to interventions seeking to move occupations towards greater sustainability (Ikiugu, Westerfield, Lien, Theisen, Cerny, & Nissen, 2015).

Finally, only one study was identified where information about occupational balance from an interpersonal perspective was studied beyond relations to partners and families (Borgh et al., 2018). This is also an area relevant for researching occupational balance from an interpersonal perspective, and more such research is needed. For instance, one of the findings was that occupational balance was enhanced in working parents by having someone to hand over to when they needed to be away from work (Borgh et al., 2018). With this focus, no knowledge exists about the occupational balance in those colleagues who take over the work. Further studies regarding factors of relevance for occupational balance in workplaces, and for who, would therefore be relevant.

Altogether, there is a need to take the interpersonal perspective more fully into account when conducting research. For instance, the results in some of the excluded articles would also have been relevant to discuss from this perspective. They concerned participants who described changes in their and their partner’s occupational patterns due to a health issue (Forsberg, Widén-Holmqvist, & Ahlström, 2015; Lund, Mangset, Wyller, & Sveen, 2013; Norberg, Boman, Löfgren, & Brännström, 2014). In these, it would have been relevant to ask both the participants and their partners how their changed pattern had affected their respective occupational balance.

Implications for occupational science

The individual perspective of occupational balance encompasses several angles: how people’s occupations match their needs (Matuska & Christiansen, 2008); how one occupation affects another occupation (Anaby, Backman, & Jarus, 2010); how time is spent in different occupations (Eklund, Erlandsson, & Leufstadius, 2010) and people’s satisfaction with their mix of occupations (Wagman, Håkansson, & Björklund, 2012). The suggested interpersonal perspective adds to these, further highlighting the complexity of the phenomenon. Recognizing that complexity might lead to needed moral/philosophical questions, such as, whose health and well-being should be enhanced. This kind of question has been described as necessary when it comes to the relationship between occupation and health (Frank, 2012) and might be of value to the development of knowledge within occupational science.

Problematizing the concept of occupational balance and determining its pros and cons (and for whom) might also be an important way to expand knowledge. The relevance and the complexity of an interpersonal perspective of occupational balance is exemplified by studies related to domestic workers. For instance, Basnyat and Chang (2016) described how the responsibility for caring for elderly family members might stress and affect family members’ occupational balance negatively. Hiring a domestic worker was described as a coping strategy, suggesting that domestic workers contribute to higher occupational balance in others. On the other hand, a lack of appropriate education among domestic workers has been reported to result in unnecessary boundaries for the care recipients (Lim & Stapleton, 2016), thus highlighting the risk of decreased occupational balance of those in their care. Furthermore, domestic workers are themselves at risk of occupational imbalance, as indicated by the following descriptions of “stressful situations, especially with regard to balancing and prioritizing the many tasks assigned to her” (Östbye, Malhotra, Malhotra, Arambepola, & Chan, 2013, p. 618).

Viewing the concept from such perspectives might be considered a way to avoid theoretical imperialism (Hammell, 2011). It might also be a way to use the critical potential of occupational science to raise “awareness of how occupation is situated in social relations of power in ways that privilege some groups while simultaneously disadvantaging others” (Laliberte Rudman, 2013, p. 300).

Methodological considerations

The use of a scoping review method (Arksey & O’Malley, 2005) was an appropriate methodological choice for the present study. However, it should be recognized that in this kind of review a quality appraisal of the included articles is not conducted, which could be considered a limitation. Neither does it provide any “relative weight of evidence” (p. 30) related to effects, in the way a systematic review does. Another possible choice could have been to conduct a critical review, considering the limited number of findings and future studies, using this method in relation to occupational balance would be valuable. Moreover, the search strategy was limited to published articles with no “grey” literature, or articles resulting from consultation or from manual searches of relevant journals.

The present study also includes one of the articles that was included in the previous scoping review (Wagman et al., 2015). This was, however, considered to be the best approach for not missing any articles of relevance. The alternative would have been to begin the search later in time, but this might not have solved the problem because studies that were published early online in the previous study might have had their final publication later and would thus have been included anyway. Another alternative would have been to exclude those articles that were included previously. It should also be recognized that the present study focused on studies related to occupational balance. Other findings might have resulted from a different aim, such as describing the importance of the interpersonal perspective regardless of whether occupational balance was explicitly included or not. Finally, it might have been a limitation to solely include primary research because potentially relevant theoretical articles might have been missed.

Conclusion

Occupational balance is a core concept in occupational therapy, known to have a relationship to health and well-being from an individual perspective. The present study aimed to describe the extent to which an interpersonal perspective on occupational balance, how one individual’s occupational balance affects and is affected by other people, has been considered by researchers. The findings show the relevance of this perspective in relation to partners in various circumstances and in relation to organizations and attitudes at the workplace. They highlighted the importance of considering the occupational balance of both the individual and those around him or her, while also showing some of the complexity of occupational balance. The limited number of articles identified indicates that there is still a lack of studies using an interpersonal perspective, suggesting that further examinations of the interpersonal influence on occupational balance may be a fruitful avenue to pursue. Therefore, further research about occupational balance from an interpersonal perspective, especially looking beyond the effect on those closest to an individual, and about its health relation from this perspective is warranted.

Disclosure statement

The authors have no conflicts of interest to declare.

ORCID

Petra Wagman http://orcid.org/0000-0002-7964-7143

Carita Håkansson http://orcid.org/0000-0002-3660-3079