Final Dissertation Tove Lise Nielsen 21 03 18 · Epidemiology Group, Aalborg University, Denmark...

Home‐based occupational therapy

for community‐dwelling older adults:

A study of effect and participants’ perspectives

PhD dissertation

Tove Lise Nielsen

Health

Aarhus University

Department of Public Health,

Section for Clinical Social Medicine and Rehabilitation

2018

PhD dissertation

©2018, Tove Lise Nielsen Department of Occupational Therapy VIA University College, Aarhus, Denmark

Supervisors

Claus Vinther Nielsen, MD, PhD, Professor Department of Public Health, Section for Clinical Social Medicine and Rehabilitation, Aarhus University, Denmark. DEFACTUM, Central Denmark Region, Denmark Kirsten Schultz Petersen, OT, PhD, Associate Professor Department of Health Science and Technology, The Faculty of Medicine, Public Health and Epidemiology Group, Aalborg University, Denmark Merete Bjerrum, MA, PhD, Associate Professor Department of Public Health, Section of Nursing Science, Aarhus University, Denmark Evaluation Committee

Aase Brandt OT, PhD, Associate Professor Research Initiative for Activity Studies and Occupational Therapy, Research Unit of General Practice, Southern University of Denmark, Odense, Denmark Kjersti Vik, OT, PhD, Professor Institut for Nevromedisin og bevegelsesvitenskap Norwegian University of Science and Technology, Trondheim, Norway Kaj Sparle Christensen, MD, PhD, Professor Department of Public Health, Section for General Medical Practice Aarhus University, Denmark

Financial support The study has received financial, material, and other support from The Tryg Foundation (Grant number J.nr.7-11-1343); The Municipality of Randers; VIA University College; Aarhus University, Department of Public Health; The Danish Association of Occupational Therapists (Grant number FF 1 13 – 10 and FF 1 17 – R45-A1276); DEFACTUM, Central Denmark Region, and The Lundbeck Foundation (travel stipend for CAOT conference in Canada).

‘Every health profession asks its clients and the public to have a level

of confidence in the worth of its services. To justify that confidence,

the profession must enable its members to offer high-quality services

which will benefit the client. Thus, when healthcare professionals

provide service to clients, the knowledge and skills they use should be

justified in terms of a systematic and shared body of professional

knowledge’

(Polgar & Thomas) [1 p.3]

The genesis of a PhD study and my sincere thanks to those who eased the

way

Throughout my professional career, I have taken great interest in the development of sound

evidence to consolidate occupational therapy (OT) interventions that can effectively improve

and maintain clients’ occupational performance and engagement. The PhD study presented

here was neither planned nor within immediate sight in 2012 when I was engaged in the data

management of a randomised controlled trial (RCT) in the municipality of Randers, designed

to evaluate the effectiveness of an intensive home-based, client-centred, and occupation-based

OT intervention for older adults. The RCT had received substantial funding from the Tryg

Foundation, and the steering committee was eager to initiate the study. I was quickly engaged

in much more than mere ‘planning of statistical analyses’; thus, I worked together with the

local leadership on adapting and expanding the study protocol; on planning and organising

inclusion, assessments and interventions; on hiring and educating the occupational therapists

to be involved in the study; on further fundraising; etc. After a short while, it seemed natural

to include the RCT in a PhD study. The RCT was launched in October 2012, and in January

2014, I was enrolled as a PhD student at the Department of Public Health, Aarhus University.

This PhD study was carried out at DEFACTUM, Central Denmark Region,

MarselisborgCentret Aarhus.

The studies included in this dissertation would never have developed into my PhD study, and

I would never have been able to submit my dissertation to Health had it not been for all the

good people and organisations who helped me along. I owe you all my heartfelt thanks:

My supervisors Claus, Kirsten, and Merete have been a tremendous help and inspiration –

thank you so much for motivating and helping me, for putting up with me and responding to

my many draft pages with zillions of reflections and questions, and for inspiring me to go in

new directions in my quest to become a researcher. Two co-authors receive my warmest

thanks: Niels and Helene, who have always been willing to discuss my work with me, to

check its quality, to help me simplify what I had made too complicated, and to elaborate on

what needed more depth. VIA University College and Aarhus University gave me the

opportunity to pursue this PhD by ensuring the basic economy. Other organisations have

supported the projects economically: DEFACTUM, Randers Kommune, the Tryg Foundation,

The Danish Organisation of Occupational Therapists, and the Lundbeck Foundation. Doing

the empirical research has involved many people: the older adults from Randers and the rest

of the country who participated in the studies, and all the professionals involved in the

organisation, enrolment, data collection, and interventions: thank you all so much for

participating in this important work! Two professional ‘homes’ have been of paramount

importance throughout my four study years: the Department of Occupational Therapy at VIA

University College Aarhus, and DEFACTUM’s research unit at MarselisborgCentret, Aarhus.

Thank you all guys, for letting me feel so included and welcome whenever I was present, for

letting me charge my batteries, participate in your discussions and fun, and receive great

professional inspiration! For two months, I was welcomed to yet a third professional ‘home’,

as Helene and Barry received me as a visiting PhD student at The Department of

Occupational Science and Occupational Therapy, University of Toronto in Toronto, Ontario,

Canada. Our interactions during and after this visit have been of seminal importance to my

professional development as an OT researcher and academic! Two co-students occupy a

special place in my heart due to our sharing of hardships, laughs, and professional exchange.

Louise and Monica: I owe you! Last but not least, my warmest thanks go to my family: my

husband Aage, my children Cecilie and Jeppe, my parents Helga and Johannes, and all the

rest of you. I am ever so grateful for your support, care, interest, inspiration, and constant

attempts at grounding me in the real world – even when I did not really wish to be! I owe my

maintained sanity entirely to you!

Tove Lise Nielsen, January 2018

Articles

The PhD dissertation is based on three articles:

Article 1. Nielsen TL, Andersen NT, Petersen KS, Polatajko H, Nielsen CV. Intensive client-

centred occupational therapy in the home improves older adults’ occupational performance.

Results from a Danish randomized controlled trial.

Published in: Scandinavian Journal of Occupational Therapy. DOI number

10.1080/11038128.2018.1424236. Published online: 12 Jan 2018. [2]

Article 2. Nielsen TL, Petersen KS, Nielsen CV, Strøm J, Ehlers MM, Bjerrum M. What are

the short-term and long-term effects of occupation-focused and occupation-based

occupational therapy in the home on older adults’ occupational performance? A systematic

review.

Published in: Scandinavian Journal of Occupational Therapy 2017;24:235-48. [3]

Article 3. Nielsen TL, Bjerrum M, Nielsen CV, Petersen KS. Older adults’ experiences and

expectations after discharge from home-based occupational therapy.

Accepted for publication by British Journal of Occupational Therapy 9 January 2018. DOI

number 10.1177/0308022618756217. In press. [4]

The three articles are found in Appendices 1–3

Abbreviations

ADL: activities of daily living

AMPS: Assessment of Motor and Process Skills

CI: confidence interval

COPM: Canadian Occupational Performance Measure

IADL: instrumental activities of daily living

ICC-OT: intensive client-centred occupational therapy

JBI: Joanna Briggs Institute

JBI-MAStARI: JBI Meta-Analysis of Statistics Assessment and Review Instrument

N or n: number of participants

OT: occupational therapy

PEO: Person-Environment-Occupation (model or factors)

PICO(C): Population Interventions Comparators Outcomes (Context)

RCT: randomised controlled trial

SD: standard deviation

SF-36: Short Form-36 Health Survey

SF-36 GH: Short Form-36 general health

TABLE OF CONTENTS

1. BACKGROUND ..................................................................................................................................... 14

1.1. Introduction ................................................................................................................................ 14

1.2. Definitions .................................................................................................................................. 15

1.3. Occupational performance in old age ........................................................................................ 16

1.4. Current practice .......................................................................................................................... 17

1.5. Effectiveness of home‐based, client‐centred, and occupation‐based OT ................................. 19

1.6. Older adults’ experiences of home‐based OT and their everyday lives post OT ....................... 21

2. AIMS AND HYPOTHESES OF THE THREE STUDIES ................................................................................... 23

2.1. Study I ......................................................................................................................................... 23

2.2. Study II ........................................................................................................................................ 24

2.3. Study III ....................................................................................................................................... 24

3. DESIGN AND METHODS ....................................................................................................................... 25

3.1. The mixed methods study design ............................................................................................... 25

3.2. Methods, Study I ........................................................................................................................ 27

3.3. Methods, Study II ....................................................................................................................... 36

3.4. Intermediate analysis between Stage 1 and Stage 2 ................................................................. 40

3.5. Methods, Study III ...................................................................................................................... 41

3.6. Ethical issues, Studies I, II, and III ............................................................................................... 47

3.7. Registration ................................................................................................................................ 48

4. RESULTS AND FINDINGS....................................................................................................................... 49

4.1. Outcomes of home‐based, client‐centred, occupation‐based OT ............................................. 49

4.2. Therapeutic and personal strategies to deal with performance problems ............................... 60

5. DISCUSSION ........................................................................................................................................ 65

5.1. Outcomes of home‐based, client‐centred, and occupation‐based OT ...................................... 65

5.2. Therapeutic approaches and strategies to deal with performance problems ........................... 69

5.3. The mixed methods design of the PhD study ............................................................................. 73

5.4. Strengths and limitations of Studies I, II, and III ......................................................................... 74

6. CONCLUSIONS ..................................................................................................................................... 78

7. IMPLICATIONS FOR PRACTICE AND RESEARCH ...................................................................................... 79

8. REFERENCES ........................................................................................................................................ 81

9. TABLES AND FIGURES .......................................................................................................................... 92

10. APPENDICES ........................................................................................................................................ 93

SUMMARY

Older adults with multiple chronic health issues can be referred to occupational therapy in

Denmark if they experience problems performing their daily occupations in their homes. The

aims of the PhD study were to examine whether home-based, client-centred, and occupation-

based occupational therapy may help older adults to improve and maintain their occupational

performance, and to understand how older adults experience and deal with their occupational

performance after they have received occupational therapy.

A sequential mixed methods design was adopted, encompassing three studies. In Study I, an

assessor-blinded randomised controlled trial with 119 older adults tested the effectiveness of

11 weeks of intensive client-centred and occupation-based occupational therapy delivered in

the older adults’ homes. The control group received the usual practice of the municipality. In

Study II, a systematic literature review of experimental research examined the effectiveness of

home-based and occupation-based occupational therapy. Eight articles reporting six RCTs

were included. In Study III, individual qualitative interviews were performed with 11 older

adults who had received home-based, client-centred, and occupation-based occupational

therapy. Their experiences and expectations concerning their occupational performance were

analysed using inductive qualitative content analysis.

In Studies I and II it was found that home-based, client-centred, and occupation-based

occupational therapy can effectively improve older adults’ occupational performance in the

short term. Study III supplemented this result with older adults’ own views on home-based

occupational therapy; they generally valued the intervention and the higher independence they

had achieved.

An evidence- and theory-based strategy chart was developed, building on findings from all

three studies concerning strategies to deal with performance problems and on the Person-

Environment-Occupation (PEO) model. General therapeutic approaches used in client-centred

and occupation-based occupational therapy were included as well as specific strategies with

two different aims: 1) to improve and maintain occupational performance and 2) to deal with

persistent performance problems.

Home-based, client-centred, and occupation-based occupational therapy can be useful for

older adults with multiple chronic and mainly physical health issues who have the energy and

motivation to participate in the intervention. The developed strategy chart can serve as a tool

to inspire occupational therapists’ tailored-to-the-individual interventions with older adults.

The results of the PhD study are applicable to home-dwelling older adults with performance

problems who live in a Scandinavian welfare state. The studied intervention seems readily

applicable to Danish municipal practice, if due consideration is given to possible needs for a

theoretical brush-up among occupational therapists, and to the allocation of sufficient

therapist resources.

Further development of interventions that emphasise the generalisation and transfer of

strategies from occupational therapy to everyday life is recommended. Future research should

examine the short- and long-term effectiveness of the interventions as well as health

economic perspectives.

DANSK RESUMÉ (SUMMARY IN DANISH)

Ældre mennesker med multiple kroniske helbredsproblemer kan henvises til ergoterapi, hvis

de har problemer med at udføre betydningsfulde daglige aktiviteter i hjemmet. Målene med

ph.d.-studiet var at undersøge, hvorvidt klientcentreret og aktivitetsbaseret ergoterapi i

hjemmet kan hjælpe ældre mennesker til at forbedre og vedligeholde deres aktivitetsudførelse

samt at forstå, hvordan ældre mennesker oplever og håndterer deres aktivitetsudførelse, efter

de har haft ergoterapi.

Et sekventielt mixed methods design blev anvendt, omfattende tre studier. Studie I var et

undersøger-blindet randomiseret kontrolleret forsøg med 119 ældre deltagere. Studiet testede

effekten af 11 ugers intensiv klientcentreret og aktivitetsbaseret ergoterapi i ældre menneskers

hjem. Kontrolgruppen modtog kommunens almindelige praksis. Studie II var et systematisk

litteraturreview af forskningsartikler om effekten af aktivitetsbaseret ergoterapi i hjemmet.

Otte artikler, der rapporterede seks randomiserede kontrollerede forsøg, blev inkluderet. I

Studie III blev individuelle, kvalitative interviews gennemført med 11 ældre mennesker, som

havde modtaget klientcentreret og aktivitetsbaseret ergoterapi i hjemmet. Deres oplevelser og

forventninger vedrørende udførelsen af betydningsfulde daglige aktiviteter blev analyseret

gennem induktiv kvalitativ indholdsanalyse.

Gennem Studie I og II blev det fundet, at klientcentreret og aktivitetsbaseret ergoterapi i

hjemmet på effektiv vis kan forbedre ældre menneskers aktivitetsudførelse på kort sigt. Studie

III supplerede dette fund med ældre menneskers egne synspunkter på ergoterapi i hjemmet; de

opfattede generelt interventionen og den opnåede øgede uafhængighed positivt.

En evidens- og teoribaseret oversigt over strategier blev udviklet, byggende på fund fra alle

tre studier vedrørende strategier til at håndtere aktivitetsproblemer samt på Person-

Environment-Occupation (PEO) modellen. Generelle terapeutiske tilgange anvendt i

klientcentreret og aktivitetsbaseret ergoterapi blev inkluderet, såvel som specifikke strategier

med to forskellige mål: 1) at forbedre og vedligeholde aktivitetsudførelse og 2) at håndtere

vedvarende/uløste aktivitetsproblemer.

Klientcentreret og aktivitetsbaseret ergoterapi i hjemmet blev således fundet effektiv for ældre

mennesker med multiple kroniske og hovedsageligt fysiske helbredsproblemer, som har

energi og motivation til at deltage i interventionen.

Den udviklede strategi-oversigt kan anvendes af ergoterapeuter som et inspirationsredskab til

at identificere og sammensætte individuelt tilpassede interventioner til ældre mennesker.

Resultaterne af ph.d.-studiet er overførbare til hjemmeboende ældre med aktivitetsproblemer,

som bor i en skandinavisk velfærdsstat. Den studerede intervention vurderes at være

umiddelbart implementerbar i dansk kommunal praksis, når der tages højde for eventuelle

behov for en teoretisk opdatering blandt ergoterapeuterne og for adgang til tilstrækkelige

personaleressourcer.

Der anbefales at arbejde videre med at udvikle interventioner, der vægtlægger generalisering

og transfer af strategier fra ergoterapien til hverdagen. Fremtidig forskning bør undersøge

såvel korttids- som langtidseffekt af interventionerne samt sundhedsøkonomiske perspektiver.

1. BACKGROUND

14

1. BACKGROUND

1.1. Introduction

Increased numbers of older adults from the large birth cohorts from the 1940s have a longer

life expectancy than previous generations owing to a better standard of living and improved

healthcare [5]. In Denmark, the proportion of older adults aged 65+ is expected to rise from

16% to 25% from 2012 to 2042 [6]. In spite of general improvements in health, a growing

number of older adults experience age-related health issues due to non-disease-specific

functional decline or due to multiple pathologies [5]. These health issues may negatively

affect older adults’ performance of daily occupations, and in consequence, they may be in

need of home care. Increased home-care costs put pressure on welfare states such as Denmark

[5]. At the personal level, older adults generally value staying active and independent of help

in their own homes as long as possible and not being a burden on others [7-12]. In Denmark,

93% of older adults aged 80–84 years live in their own homes; for those aged 85+, the

percentage is 86% [6]. The vast majority of older adults in Denmark live alone or with a

spouse; one-third of older adults aged 65 to 79 years and two-thirds of older adults aged 80+

live alone [13]. The importance of being able to care for oneself should therefore be seen in

light of the fact that often no healthy family member is present to share the household chores

with or to have a helping hand from when needed. One way of diminishing older adults’

difficulties with occupational performance and the need for home care is to try to help them to

decelerate their functional decline and regain their functional independence through

rehabilitation. Occupational therapists play an important role in this strategy because

occupational therapy (OT) focuses on maintaining and increasing occupational performance,

social participation, and quality of life [14,15]. Scientific evidence and theory exist that

support OT programmes for older adults, some of which are home-based, client-centred, or

occupation-based [e.g. 16-21]. Yet little scientific evidence exists to guide practice

concerning the effectiveness and the planning of OT interventions that clearly encompass all

these three characteristics, and little is known about how participation in such interventions

may affect older adults’ occupational performance after they have had OT (in the dissertation

also described as post OT). This was the situation when occupational therapists in the

municipality of Randers were asked to justify their comprehensive OT services in older

1. BACKGROUND

15

adults’ homes, and as they had no satisfactory answer to hand, they conceived the idea behind

the randomised controlled trial (RCT) that is included in the present PhD study.

The overall aims of the PhD study are to examine whether home-based, client-centred, and

occupation-based OT may help older adults to improve and maintain their occupational

performance, and to understand how older adults experience their occupational performance

post OT.

1.2. Definitions

In this PhD study, older adults are defined as being > 60 years old. Definitions concerning

occupations, activity, and occupational performance need to be briefly introduced.

Occupations

‘Groups of activities and tasks of everyday life, named, organized, and given value by

individuals and in a culture; occupation is everything people do to occupy themselves,

including looking after themselves (self-care), enjoying life (leisure), and contributing to the

social and economic fabric of their communities (productivity)’ (CAOT 2002) [22]

Activity

‘The execution of a task or action by an individual’ [21]. In this dissertation, activity is

defined as a specific activity performed (or not performed) in an older adult’s daily life or

worked on during OT [21]. The terms self-care, leisure, and productivity define specific

groups of activities. Other terms, e.g. activities of daily living (ADL) and instrumental

activities of daily living (IADL), will be used in the dissertation only when citing references

using them.

Occupational performance

‘The result of a dynamic, interwoven relationship between person, environment, and

occupation over a person’s lifespan’ (CAOT 2002) [22]. The domain of concern and the

therapeutic medium of OT.

1. BACKGROUND

16

The Person-Environment-Occupation (PEO) Model of Occupational Performance depicts how

occupational performance takes place in an interaction among the components person,

environment, and occupation, see Figure 1. Occupational performance is a function of the fit

(or lack of fit) between a person’s abilities and skills, the environmental conditions under

which occupation takes place, and the demands of a particular occupation [23].

Figure 1. The Person‐Environment‐Occupation (PEO) Model Inspired by [23]

1.3. Occupational performance in old age

Staying active and independent of help in one’s own home includes continuing to perform the

occupations one wants to, needs to, and is expected to perform [21]. Older adults’

occupational performance has been associated with life satisfaction, quality of life, and a

range of health benefits, such as protection against functional limitations, reduced disease

severity, and slowed progression of disability [24-27]. Older adults’ occupational

performance may be hampered due to a misfit between two or more of the components of the

PEO model, namely, the person, the environment, or the occupation [15]. Hence, performance

problems can develop due to acute health issues, intercurrent disease, slowly progressive

diseases, or more general ageing processes [18,28-32]. Often multiple chronic health issues

are present. Performance problems can also be due to environmental factors such as lack of

accessibility in the home, in public spaces, and to public transport, and to social factors such

as financial problems or lack of social support [28-32]. Older adults’ individual perspectives

affect not only what they are able and need to do but also what they want and choose to do,

1. BACKGROUND

17

and decreased occupational performance among home-dwelling older adults therefore

encompasses all types of activities [29,31,33-35].

1.4. Current practice

Danish ageing policy supports older adults’ continued self-sufficiency, well-being, and ageing

in place (i.e. remaining in the community with some level of independence rather than in

residential care) for economic and humane reasons [5,7,36]. The municipalities (the local

authorities) pursue these goals through programmes aimed at prevention, reablement, and

compensation. Older adults are offered preventive home visits, rehabilitation, assistive

devices, minor home modifications, and personal or practical help (home care) free of charge

when certain criteria are met [37-39]. Rehabilitation of older adults in Denmark primarily

takes place in the municipalities. It may commence at hospitals, yet at discharge, the

responsibility is passed on to the municipalities by means of a rehabilitation plan [38]. The

municipalities are also obliged to offer rehabilitation to persons with impaired physical

function who have not been hospitalised [37]. In addition, the municipalities are obliged to

assess whether a person in need of home-care services could benefit from an individualised

rehabilitation programme (reablement) aiming at regaining physical or social function and

achieving a better quality of life [36]. Several professions are involved, typically occupational

therapists, physiotherapists, nurses, and home-care assistants.

Occupational therapists take part in the individual rehabilitation of older adults with an aim to

improve and maintain occupational performance and wellbeing. OT with these aims is

delivered in two typical ways: as comprehensive, client-centred OT, or as an element in

home-care reablement. In both cases, OT is often delivered in conjunction with the services of

other healthcare professionals. The present PhD study is about comprehensive, client-centred

OT, with a special focus on mono-disciplinary OT. Comprehensive OT takes its starting point

in the older adults’ expressed performance problems, and a tailored-to-the-individual

intervention is planned through various therapeutic strategies [40]. Polatajko et al. describe

therapeutic strategies as: ‘change strategies targeting individual occupations’, and they can

‘address aspects of the person, the occupation or the environment, singly or in combination’

[40]. OT theory supports rehabilitation that is home-based, client-centred, and occupation-

based, and comprehensive OT for older adults in the Danish municipalities often encompasses

1. BACKGROUND

18

these three features [19-21]. The combination of the features, home-based, client-centred, and

occupation-based, is therefore in focus in each of the three studies comprising the present

PhD study. The features will be further introduced here.

Home‐based occupational therapy

Home-based OT is in the present PhD study defined as OT performed by registered

occupational therapists in the older adults’ homes and in other natural or built environments

of relevance to the older adults’ daily occupations, but not in institutional settings. The home

as setting for OT is perceived positively by most older adults but not by all. Thus, some older

adults have related that being in their natural surroundings, they could engage in meaningful

and life-relevant occupations, increase their confidence, avoid the stress associated with

transport and waiting time, and talk more freely with the therapy staff than in a hospital [41-

43]. However, some older adults have expressed that it was a disadvantage to have therapy in

the home because it was ‘less serious’ or because the familiarity of the home distracted them

during sessions [43]. Occupational therapists have generally found the home setting

advantageous, because more realistic assessments of older adults’ performance levels can be

made in the home than in clinical surroundings [44,45] and because more appropriate and

individualised programmes of intervention can be designed as a result of direct assessment of

the home environment [43]. The overweight of positive experiences, and the argument that

client-centred practice (see below) is best embodied in the natural environment of everyday

living [46] led to the choice of the home as setting for the present PhD study.

Client‐centred occupational therapy

In its ethical guidelines, The Danish Association of Occupational Therapists emphasises the

importance of establishing a partnership between the client and the occupational therapist

based on mutual respect, equality, and credibility [47]. These principles are in congruence

with those of client-centred OT, according to Canadian OT theory defined as ‘collaborative

approaches aimed at enabling occupation with clients’ [48]. In client-centred OT,

occupational therapists ‘demonstrate respect for clients, involve clients in decision-making,

advocate with and for clients in meeting clients’ needs, and otherwise recognize clients’

experience and knowledge’ [48]. Client-centred OT is generally recognised and practised

within Danish OT, informed by Canadian and US conceptual and practice models and

assessments [19, 21, 48-50].

1. BACKGROUND

19

Research has shown that client-centred OT practice for adults with different physical health

issues can improve their occupational performance, increase their feelings of being involved,

and improve satisfaction with services [e.g. 51,52]. Yet an RCT among stroke patients, testing

a specific client-centred OT intervention versus usual therapeutic practice, yielded no

between-group differences in self-care or perceived participation [53]. In the municipality of

Randers, where the RCT (Study I) of the present PhD study took place, occupational

therapists were discussing their possibilities of delivering client-centred OT. They

problematised the limited degree of choice the older adults were allowed concerning which

performance problems to address during home-care reablement, and they feared that this

would erode the older adults’ access to valued occupations.

Occupation‐based occupational therapy

According to Danish practice, OT for older adults in their home is often occupation-based.

The aim of the intervention is improved or maintained occupational performance [19,20,54],

and during OT, the older adult is typically engaged in activities that match identified goals

[20,55]. However, other types of intervention may be included, too, depending on the reasons

for the identified performance problems [19,54]. During occupation-based OT, the

occupational therapist implements individually adapted therapeutic strategies considering the

PEO factors [40]. Evidence that the use of daily occupations within OT for older adults leads

to improved occupational performance has been widely reported [16,51,56]. Occupation-

based OT has by older adults and other client groups been deemed more motivating,

meaningful, and satisfying than other kinds of OT, such as rote practice [57,58].

1.5. Effectiveness of home‐based, client‐centred, and occupation‐based OT

In accordance with professional guidelines and contemporary understandings of evidence-

based healthcare, occupational therapists are obliged to work in an evidence-based manner

and keep themselves updated on the best practice in their field [59,60]. Literature reviews and

meta-analyses can help practitioners and scientists to get an overview of existing scientific

knowledge. The effectiveness of OT for older adults with performance problems due to

various health issues was examined in a meta-analysis back in 1996; beneficial treatment

effects extended to occupational performance and psychosocial outcomes, and a highly

1. BACKGROUND

20

significant cumulative result for treatment success was reported (p < 0.001) [61]. However,

the results stemmed from studies with a great diversity of treatment contexts, interventions,

participants, and outcomes, and there was no attention given to whether the interventions

were home-based, client-centred, or occupation-based. Since then, a number of literature

reviews targeting more specific questions concerning OT for older adults have been

published, and four methodologically sound reviews published within the last 10 years report

on the effectiveness of home-based and occupation-based interventions for adults after a

stroke (no age limit) [56], for frail older adults [16], for home-care service users [17], and for

adults and older adults with a health condition [62].

Overall, these four reviews provide limited to strong evidence that home-based and

occupation-based interventions that include OT can effectively improve adults’ and older

adults’ occupational performance, in some studies limited to self-care activities or leisure

activities. In addition, one review shows that interventions focused on home modifications

can help limit functional decline over time [62]. Although the reviews report the effectiveness

of home-based and occupation-based OT, not all participants in the included studies were

older adults, and one review included only stroke studies. Furthermore, the studies varied

concerning whether OT was delivered as a mono-disciplinary or a multidisciplinary approach

and concerning which types of performance problems could be addressed. All reviews

evaluated studies of occupation-based interventions (although not always defined as such);

only two reviews reported whether a client-centred approach was adopted in the included

studies [16,17]. Thus, little is known about how effective comprehensive OT which combines

the three components, home-based, client-centred, and occupation-based, is at improving

occupational performance in older adults with multiple chronic health issues.

None of the abovementioned four literature reviews discuss the intensity of the OT

interventions. Previous studies from inpatient settings show that the amount of OT and

physiotherapy influenced the outcome among patients with traumatic brain injury, stroke, and

orthopaedic problems, and in several cases, they concluded that the amount of intervention

was far too small to be effective [63,64]. In some studies, home-based OT interventions have

been limited to very few OT visits [e.g. 65]. Dawson et al. have suggested that problem-

solving strategies, which are often introduced during occupation-based OT, are implemented

into daily occupational performance in three phases: acquisition (adopting a strategy during

the therapy sessions), generalisation (using the strategy outside sessions), and transfer to

1. BACKGROUND

21

other goals [66]. Sufficient time is required for this process if problem solving is to become a

fruitful strategy for older adults in their daily lives, and other types of strategies may also take

time to learn and generalise. It therefore seems important to focus on amount and intensity of

OT when planning interventions and subsequently when discussing their effectiveness;

however, research on intensive home-based OT interventions is scarce.

It is important to assess not only the immediate outcomes at the end of an OT intervention,

but also the impact of OT intervention on occupational performance post OT. The latter

mirrors the degree to which new strategies and achieved improvements have been generalised

and implemented in everyday life and subsequently maintained post OT [66]. Older adults’

loss of improvements achieved during OT and multidisciplinary rehabilitation has been

documented [67-70]. There therefore seems to be a need for a strengthened focus on

programme development and evaluation regarding how improvements achieved by older

adults through home-based OT are implemented and maintained post OT.

1.6. Older adults’ experiences of home‐based OT and their everyday lives post

OT

As professionals, we do not see or experience OT and everyday life in the same way as the

users of our services [71], and qualitative research among users can therefore lead to

important insights into processes of change and intervention outcomes [72]. Thus, qualitative

evidence can help us understand how older adults manage their occupational performance and

how home-based OT may affect older adults’ daily lives during and after the intervention.

This may include what the outcomes of OT mean to the older adults, which therapeutic

strategies they have found useful and less useful, and which personal strategies they apply to

deal with their occupational performance post OT.

Older adults have shared their experiences about their participation in home-based OT,

delivered in either a mono-disciplinary or a multidisciplinary fashion. Some have related that

they perceived the process of choosing goals to be collaborative, yet in some cases, the

collaboration was not extended to the choice of interventions, which was solely made by the

occupational therapists [41,73].

1. BACKGROUND

22

Positive experiences of collaboration in the goal-setting process and during subsequent

interventions have also been reported [41]. Improvements in occupational performance

resulting from home-based OT have been reported and linked to feelings of safety, increased

independence, re-entry into social life, and improved role functioning [41,42,74]. Feelings of

frustration in relation to unachieved goals have also been expressed [42].

Older adults’ personal strategies to deal with their occupational performance have been

studied, too. A Canadian study of coping strategies among older adults with health issues who

had not undergone OT showed that seeking social support, using planful problem solving,

distancing, self-control, and positive reappraisal were common [75]. Studies among older

adults, after rehabilitation, have shown that they often strive to improve further and to

maintain their occupational performance [11,74,76], using various strategies such as to plan

and continue important activities, train and maintain bodily functions, do things in other ways,

prioritise, and receive help [11,74,76]. Strategies like having internal dialogues to change

one’s view on the situation [76], being content as long as one is not a burden on the family,

and comparing one’s situation to others who are worse off [11] have also been reported.

No previous studies seem to have focused on older adults’ experienced outcomes pertaining

to their occupational performance after they had received OT, particularly defined as home-

based, client-centred, and occupation-based. It is unknown which strategies the older adults

use to deal with their occupational performance after OT and which strategies they expect to

use in the future. Such knowledge may provide a deeper understanding of outcomes of OT

and inspire and supplement the therapeutic strategies used by occupational therapists to

improve older adults’ occupational performance.

2. AIMS AND HYPOTHESES OF THE THREE STUDIES

23


Little scientific evidence exists concerning the effectiveness of an OT intervention that

combines the features home-based, client-centred, and occupation-based, delivered in a

mainly mono-disciplinary fashion to older adults with multiple chronic health issues. Thus,

knowledge is needed to inform practice whether such interventions may effectively improve

older adults’ occupational performance. Furthermore, knowledge is scarce concerning older

adults’ experiences of their occupational performance post OT, and about which strategies

they may find useful to deal with their occupational performance. The overall aims of the PhD

study are therefore to examine whether home-based, client-centred, and occupation-based OT

may help older adults to improve and maintain their occupational performance, and to

understand how older adults experience and deal with their occupational performance post

OT. The answers to these questions will be used to inform occupational therapists and

administrators about the effectiveness and applicability of home-based, client-centred, and

occupation-based OT and to provide ideas for practice. To achieve the overall aims, three

studies were performed.

2.1. Study I

Objective: to compare 11 weeks of occupation-based, intensive, client-centred OT (ICC-OT;

ICC stands for intensive, client-centred) in the homes of older adults to the usual practice of a

Danish municipality and test the primary hypothesis:

ICC-OT will be superior to usual practice in improving the participants’ self-reported

occupational performance, thus the ICC-OT group will improve more from baseline to 3

months after baseline than the Usual-Practice group.

Differences regarding secondary outcomes were explored, too, building on expectations that

the ICC-OT would similarly outperform usual practice after 3 months on two counts:

satisfaction with occupational performance and quality of occupational performance.

Finally, we expected that improvements in the ICC-OT group would be larger 6 months after

baseline on all outcomes, i.e. compared with baseline, than in the Usual-Practice group.


24

2.2. Study II

Objective: To review existing scientific evidence from experimental research on the

effectiveness of home-based, client-centred, and occupation-based OT, through the following

review question:

What are the short-term and long-term effects of occupation-focused and occupation-

based OT in the home on older adults’ occupational performance?

2.3. Study III

Objective: To extend current understandings of older adults’ experiences and expectations

concerning their occupational performance after home-based, client-centred, and occupation-

based OT by answering two primary research questions:

How do older adults who have received home-based, client-centred, and occupation-based

OT experience their occupational performance post OT?

What do older adults who have received home-based, client-centred, and occupation-

based OT expect concerning their occupational performance in the future?

3. DESIGN AND METHODS

25


3.1. The mixed methods study design

To achieve the aims of the PhD study, both quantitative and qualitative evidence was sought,

and this led to the choice of a mixed methods methodology and to the sequential mixed

methods design depicted in Figure 2 [77]. The design consists of two distinct stages: a

primary quantitative stage followed up by a secondary qualitative stage.

Figure 2. The mixed‐methods design of the PhD study

As the aim of the PhD study called for both quantitative and qualitative methods, the study

built on different theoretical positions: beliefs and assumptions about knowledge [77 p.38-

47]. In the first, quantitative stage, a randomised controlled trial (RCT) (Study I) was

performed to test whether intensive client-centred OT (ICC-OT) delivered in the home would

effectively improve older adults’ occupational performance. In addition, a systematic

literature review (Study II) of experimental research was carried out to review current

evidence concerning home-based, client-centred, and occupation-based OT for older adults,

and six RCTs were included. The focus of the literature review was on statistically supported

evidence of the interventions’ potential to improve older adults’ occupational performance,


26

and on the therapeutic approaches. The RCTs in Stage 1 built on cause-and-effect thinking, on

detailed observations and measures of variables, and on hypothesis testing [77]. Conclusions

could be statistically generalised to cover the whole population of which the samples were

representative [78].

As Figure 2 shows, an intermediate analysis took place after the first stage. This analysis led

to the identification of challenges and knowledge gaps pertaining to outcomes and processes

of home-based, client-centred, and occupation-based OT for older adults. The analysis built

on the first two studies and formed a basis for specifying the qualitative research questions to

be addressed in the second stage of the PhD study [77].

In the second, qualitative stage of the PhD study, an interview study was performed and

analysed using inductive qualitative content analysis [79,80]. It was examined how older

adults experienced their occupational performance post OT, and which feelings, values, and

strategies they related to their present and future occupational performance in order to

improve the understanding of the older adults’ being-in-the-world from their own

perspectives [79,81,82]. The results from this study supplemented the quantitative results

from Stage 1 with the older adults’ experiences, and analytical generalisation enabled the

development of suggestions for future interventions [83].

Finally, in this dissertation, knowledge emerging from all three studies is presented,

synthesised, and discussed in the light of the methods applied [77]. Quantitative results

concerning effectiveness of home-based, client-centred, and occupation-based OT and older

adults’ experienced outcomes from such interventions are now interpreted together to provide

a fuller picture of what older adults can gain from receiving this kind of OT. In addition,

findings from Studies I and II concerning therapeutic strategies are merged with findings from

Study III about therapeutic and personal strategies used by the older adults to deal with their

occupational performance post OT. These findings are discussed and used to suggest how

home-based, client-centred, and occupation-based OT interventions may be improved.


27

3.2. Methods, Study I

An experimental design was chosen to test whether Intensive Client-Centred OT (ICC-OT)

delivered in the home would effectively improve older adults’ occupational performance.

A randomised controlled trial was performed, with assessor-masked assessments at baseline,

and 3 and 6 months after baseline.

Sampling and randomisation

The inclusion and exclusion criteria are shown in Table 1. Older adults were included who

would, at the time of the study, be considered for rehabilitative services in the municipality

where the study was performed. They were not allowed to have been involved in

rehabilitation (planning or practice) immediately before the RCT or to live with a former

study participant; this was decided to avoid contamination from other interventions or

between the groups.

Table 1. In‐ and exclusion criteria for Study I [2]

Population

Age 60+.

Living in a private home or sheltered (senior) housing.

Experiencing performance problems and therefore applying for, or already receiving, home‐care

services.

Danish speaking.

Exclusion criteria were alcohol or drug abuse, dementia, severe mental illness or severe intellectual

disability, tetraplegia, severe pain, rapidly progressive diseases such as cancer or motor neuron

disease.

Further exclusion criteria were having a rehabilitation plan from a hospital, former participation in

home‐care reablement, or living with a participant of the present study.

The study took place in Randers Kommune, a Danish Municipality with 97,500 inhabitants

[84]. A computerised procedure, generated by a data management team, was used to allocate

participants to the two study groups to ensure that the process was blinded and truly random.

One hundred and nineteen participants were included. Figure 3 illustrates the participant flow.


28

Figure 3. Participant flow. Study I [2]


29

Interventions: ICC‐OT and usual practice

The RCT was carried out in a municipality where local policies and practices could not all be

set aside during a scientific study. Thus, the study took place within the usual home-care

context and tested the effectiveness of ICC-OT versus usual practice. All participants in both

groups could receive the standard services of the municipality throughout the study period,

including help with personal care, practical help (mainly for housekeeping), meal delivery,

assistive devices, minor home modifications, and physiotherapy, when meeting specified

requirements. The differences between the groups with regard to OT and home-care

reablement were as explained below.

For the intervention group (the ICC-OT group), the protocol specified up to 11 weeks of ICC-

OT with two sessions per week. The intensity was chosen to allow time to work on several

performance problems defined by the older adult, and time to achieve generalisation to

situations where the occupational therapist was no longer present [66]. The intervention was

tailored to each individual older adult. The interview-based and validated Canadian

Occupational Performance Measure (COPM), developed specifically to support client-centred

OT practice, was used to help the older adults describe their most important performance

problems and to prioritise what to work on [50,85-87]. In acknowledgement of the client-

centred focus of the intervention, it was stressed that free choice of what to work on was an

important feature of the intervention. New performance problems that emerged during the

period of ICC-OT, and were considered important by the older adults, could therefore be

worked on too. Goal setting and intervention planning were based on the older adults’

priorities. Occupational performance was both the aim and primary means, and it was

emphasised that the intervention should to a large degree involve practising the necessary

activities to achieve the goals, and that acquisitional, adaptive, and restorative models should

be applied because they support an occupation-based approach [19,20]. The home-based

intervention is depicted in Figure 4. At the end of the intervention, the 3-month assessment

was carried out, and the older adults received usual practice for the last 3 months of their

study participation, until the 6-month assessment.

The Usual-Practice group could, in addition to the previously described standard services of

the municipality, be referred to home-care reablement if the home-care officer found they had

potential for improved independence that could lead to a decreased need for home care.


30

The activities worked on were typically self-care activities and activities pertaining to

housekeeping. Home-care reablement, as practised in Randers Kommune at the time of the

study, was home-based and lasted up to 3 weeks. The intervention was not defined as client-

centred, and there was no free choice for the older adults concerning what to work on. During

home-care reablement, the older adults practised the activities they otherwise needed home

care for, and they received advice and help when needed, e.g. on how to simplify a task or to

use an assistive device. The reablement was predominantly performed by home-care

assistants, yet up to three visits by an occupational therapist could be included. The Usual-

Practice group had usual practice the full 6 months they participated in the study.

Reassessments were carried out at 3 months and at 6 months.


31

Figure 4. Characteristics of the ICC‐OT intervention. Study I [2]


32

Outcomes

At baseline, at 3 months, and at 6 months, occupational performance and health-related

quality of life were assessed with internationally accepted outcome measures that were all

validated in populations of older adults and in home settings. Two assessments of

occupational performance were used: an interview-based and an observation-based

assessment, as recommended in the literature, since the two methods assess functional ability

from different aspects and thus provide different information [88-90].

The interview-based COPM was the primary outcome measure due to its inherent client-

centred scope [50,91] and its good properties to identify and assess performance problems

[86,87,92]. It contains two scales: the performance scale and the performance satisfaction

scale (from now on called the satisfaction scale). The performance score was chosen as the

primary outcome, since improved performance was the aim of the ICC-OT intervention, and

we were interested in how well the older adults themselves perceived their performance of the

activities they had identified as challenging. This could not have been achieved using an

outcome measure containing predefined activities [93]. The satisfaction score was used as a

secondary outcome. The COPM has been used by researchers in a number of RCTs and other

intervention studies around the world [85]. Details on how the COPM was performed and

how the scores were computed are found in Article 1 [2]. For the ICC-OT group, we had not

predefined that a given number of COPM performance problems should be targeted during

therapy, and the number worked on varied. Although some transfer of improved skills from

trained to untrained problems may have played a role [94], one would believe that there

should be a greater chance to improve a trained than an untrained activity. This implies that

the participants in the ICC-OT group may have had different chances of achieving a

measurable improvement on the COPM, dependent on how many COPM performance

problems they had actually worked on.

The observation-based Assessment of Motor and Process Skills (AMPS) was used as a

secondary outcome measure [45,55,95-97]. The AMPS assesses performance quality

understood as the degree to which a person’s task performance is free from increased

clumsiness or physical effort, decreased efficiency, safety risk, and/or need for assistance

[55]. A motor score and a process score were computed, and both were used as secondary

outcomes.


33

Details on how the AMPS was performed and how the scores were computed are found in

Article 1 [2]. To be able to use the AMPS in a valid way, the assessors were trained and had

completed a calibration process. To further ensure the validity of the AMPS results, a post

hoc analysis of all AMPS assessments was performed [98], and 97% of all assessments were

deemed free of rater scoring error and included in the analyses.

The self-reported Short Form 36 (SF-36), a generic measure of health-related quality of life

[99-103], was in this study used in an interview setting [103] to ensure that all questions were

understood and no questions ignored. Details on how the SF-36 was performed and how the

scores were computed are found in Article 1 [2]. The computations lead to eight subscales, of

which the General Health subscale (SF-36 GH) was used in exploratory analyses.

Research occupational therapists and assessors

It was of utmost importance to the reliability and validity of the study that contamination

between the two study groups was avoided, and that the occupational therapists involved in

assessments and treatments followed the study protocol and used the outcome measures as

intended. Thus, the two research occupational therapists who performed the baseline

assessments and delivered the ICC-OT did not interact with any occupational therapists who

served the Usual-Practice group, because inspiration from the principles and therapeutic

strategies used during ICC-OT could have influenced (contaminated) usual practice. From the

perspective of controlling the content and processes of the ICC-OT intervention, it was a good

thing that only two occupational therapists delivered the intervention. At the same time, the

interventions were very much dependent on only two therapists’ understandings of how to

deliver ICC-OT. The research occupational therapists were therefore educated in performing

the ICC-OT before the study, and team meetings were held during the study to further

improve their intervention skills and protocol adherence. The theoretical foundations of the

ICC-OT, especially the principles concerning client-centred OT [21,22,49] were emphasised

and discussed. In addition to the two research occupational therapists, four occupational

therapists were hired to perform the assessments at 3 and 6 months. We ensured that all six

assessors were experienced users of the COPM and the AMPS with older adults, and they

were educated to use the SF-36. Assessor skills were further strengthened at educational

workshops and team meetings before and during the study.


34

Masking

To avoid assessor bias, the study was assessor-masked (single blind). The older adults, of

course, knew whether they had received ICC-OT or not, but they were urged not to disclose

this to their assessors, and they were not shown the results of previous assessments. In some

studies, assessors have been asked whether they had guessed a participant’s allocation status

after an assessment, yet it is not a general recommendation to do so [104]. We preferred not to

do this in order not to spur any attempts, among the occupational therapists, at guessing the

randomisation status during the assessments.

Data management and analysis

The sample size calculation related to the primary outcome measure, the COPM. We used a

minimal clinically important difference of 2 points [92] and a standard deviation (SD) of 2.22

[105]. An alpha level of 0.05 (two-sided) and a power of 80% were decided upon. This led to

a sample size of 20 participants in each group. As we expected there would be a high attrition

rate due to the age and general health of the target group [106], and as we wanted to perform

secondary analyses, we settled for a sample size of 120 participants. The analyses were

performed by original assigned groups (intention-to-treat) on all available data. Stata 12 was

used for the analyses [107]. The significance level was set at 0.05, and two-sided tests were

performed.

The analyses performed to test the primary and the secondary hypotheses were made on

change scores from baseline to 3 months and from baseline to 6 months. The between-group

differences in change were tested using t-tests for independent samples. Exploratory analyses

on within-group changes were also performed to analyse whether statistically significant

changes had taken place within each group at 3 and at 6 months. These changes were tested

using t-tests for paired samples. To analyse categorical outcomes, chi-square tests were used.

Because previous studies have shown associations between occupational performance and one

or more of the three variables, age, general health, and sex [29,30,108,109], we explored

possible effect modification concerning these three variables by multiple linear regression

analyses of the main outcome, COPM performance. Due to loss to follow-up at 3 months,

where the main hypothesis was tested, and because perceived general health tended to modify

the effect of the ICC-OT intervention on the COPM performance score, we performed a

single value imputation of COPM performance change scores for the dissertation.


35

The imputed values were generated using three different linear regression models; all

included the SF-36 GH score at baseline, and one also included age and sex.

Pragmatic and explanatory features of Study I

To evaluate the usefulness of the results of Study I to Danish municipalities, the Pragmatic

Explanatory Continuum Indicator Summary tool (PRECIS-2) was used to consider how the

design decisions could lead to a more applicable/pragmatic or to a more explanatory trial

[110]. According to Loudon et al., a pragmatic RCT ‘is aimed at maximising applicability of

the intervention to usual care across a range of local and distant settings’ [110], while an

explanatory RCT ‘is aimed at maximising the intervention’s chance of demonstrating an

effect through the expected mechanism, with little attention paid to the issue of whether this

outcome would be achieved under real world conditions’ [110].

The highly pragmatic features of Study I apply to eligibility, setting, organisation, primary

outcome, and primary analysis. Thus, we included participants similar to those who would

usually be considered for rehabilitative interventions in the municipality of Randers,

following the usual recruitment path. The study was carried out in the usual home-care

setting. Apart from OT, all participants could have the usual home-care services of the

municipality. The primary outcome was of high relevance for the participants since they

personally defined and prioritised on the COPM which performance problems to assess and to

address during OT. Finally, all available data were included in the (intention-to-treat)

analysis.

The features pertaining to a more explanatory approach apply to recruitment, organisation,

flexibility concerning adherence, and follow-up. The study participants were informed more

thoroughly than they would have been in the usual care setting. Only one Danish

municipality, Randers, was involved in the trial; however, Randers is an average Danish

municipality [111]. The occupational therapists providing the ICC-OT were experienced in

working with older adults and further trained for the study. In usual care, there was a mix of

experienced and less experienced therapists, and not all would know the principles and

strategies used for client-centred and occupation-based OT. More emphasis was put on

adherence to OT in Study I than there would have been in usual practice.


36

Finally, the assessment schedule was more intensive than in usual practice, where, at the

most, assessments would have been performed at the beginning of OT and at the end of the

intervention.

Thus, Study I had some key features that can be ascribed to a pragmatic RCT and some that

can more readily be ascribed to an explanatory RCT. These features will be considered in the

discussion in Chapter 5.

3.3. Methods, Study II

The systematic literature review was conducted in accordance with guidelines from the

Joanna Briggs’ Institute (JBI) [60,112], which enabled a thorough and transparent review

process. A seven-stage process was followed: 1) Formulation of review question, 2)

Formulation of inclusion criteria and search strategy, 3) Conduct of literature search, 4)

Assessment of relevance, 5) Assessment of methodological quality by three reviewers, 6)

Data extraction and 7) Data analysis and synthesis [112]. The Population Interventions

Comparators Outcomes (Context) (PICO(C)) framework guided the structuring of the review

question, framed the in- and exclusion criteria, and was used to plan the search strategy, as

this framework has been deemed valuable for structuring clinical therapy questions [112-114].

Sampling

For the systematic literature review, the inclusion criteria ensured that the populations of the

included articles were as similar as possible to the older adults included in Study I to facilitate

joint conclusions to be drawn at a later stage. The inclusion criteria also ensured that the

effectiveness of home-based and occupation-based OT was tested. An initial literature search

revealed only a few articles on home-based OT for older adults where the term client-centred

was used as keyword. In the review, it was therefore not a mandatory inclusion criterion that

the interventions should be described as client-centred. Instead, the articles were examined for

descriptions of the cooperation between the older adult and the occupational therapist, for

example on goal setting, and these features were reported in the review. To operationalise the

concept occupation-based, it was defined that to be included the articles should clearly show

that occupational performance had been assessed before and after the intervention, that the

aim of OT was to improve occupational performance, and that activities had been practised as

a major part of the intervention.


37

This was in congruence with Fisher’s description of occupation-focused and occupation-based

assessments and interventions [20]. Inclusion and exclusion criteria are presented in Table 2.

Table 2. In‐ and exclusion criteria for Study II [3]

Population

Only studies where the participants were 60+ years were included; if there was no such distinct

inclusion criterion in a study, the study could be included if a 95% confidence interval formed around

the mean age of the participants did not include 59 years or lower. In addition, the participants

should be home dwelling and have a reduced level of functioning due to health issues.

Excluded were studies among older adults with dementia or terminal stage cancer .

Intervention

Occupation‐based and occupation‐focused OT. The major parts of planning and execution were

performed by occupational therapists.

Excluded were studies of interventions with a main focus on prevention of functional decline in well

older adults, on prevention of falls, on driving a car, or on provision of assistive devices or home

modifications without a specific focus on practising activities. Excluded were also studies of the effect

of pre‐discharge home visits.

Comparator

The comparator could be another OT intervention, usual practice, or no intervention.

Outcom

The articles should present quantitatively measured between‐group differences in occupational

performance, assessed using validated outcome measures.

Context

The interventions tested should be carried out in the homes or in other natural or built environments

where the participants’ occupational performance usually took place.

Excluded were studies where all or some interventions took place in institutional settings such as

rehab centres or hospitals.

Studies

Eligible were primary, quantitative, or mixed methods studies of experimental design that addressed

effectiveness. No time restriction was established, as no previous reviews had been found addressing

the research question. Articles written in English, German, Danish, Norwegian, or Swedish and

published in peer‐reviewed journals could be included.

Excluded were literature reviews or meta‐analyses, studies with a primary health economic

perspective, as well as feasibility or pilot studies.

The systematic literature search was conducted in consultation with science librarians to

ensure a rigorous and systematic approach. The seven online databases (Cochrane, PubMed,

Embase, CINAHL, Psych INFO, SveMed+, and OT Seeker) were chosen based on my own

and the librarians’ experiences regarding where to look for articles reporting OT studies.


38

Initial keywords and an example of a search string are given in Article 2 [3]. A flow diagram

of the process of searching, selecting, and assessing articles for inclusion as recommended by

PRISMA is found in Figure 5 [115].

Figure 5. PRISMA flow diagram. Study 2


39

After removal of redundant findings and a thorough assessment of the remaining 995 articles

for relevance, I read 30 selected articles in full length; when doubt arose concerning their

relevance, a senior reviewer was consulted and agreement achieved through consensus

discussion. Finally, the methodological quality of 13 articles was appraised; three independent

reviewers were involved to ensure a rigorous approach [112]. The critical appraisal checklist

JBI Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was used

[112]. This standardised checklist consists of 10 questions pertaining to risk of bias. The JBI-

MAStARI has no defined cut-off to guide whether to include or exclude a study based on

methodological quality, but it is recommended to decide beforehand whether a certain

predetermined proportion of all criteria or whether certain specific criteria should be met

[112]. It was decided that at least 75% of the criteria should be satisfactorily met for an article

to be included in the review. We did not specifically identify any criteria to be obligatorily

met, which, in hindsight, could have made sense. Thus, some criteria are thought to be more

important in assessing risk of bias than are others [116], and, contrariwise, a criterion about

masking the participants concerning the intervention received is usually not feasible in an

intervention study within OT or other forms of rehabilitation [116, 117]. Consensus

discussions among the reviewers helped resolve disagreements concerning ratings, and eight

articles were kept for review [65, 118-124]. The eight articles reported six different studies.

Seven of the included articles received eight and one article received nine out of the ten points

on the JBI-MAStARI checklist. The question concerning blinding of the participants was not

fulfilled by any study, and in only one study were the outcomes of people who withdrew

described and included in the analysis. For more details on the appraisal, consult Paper 2 [3].

Data collection

Data from the included eight articles were extracted using templates adapted from the JBI-

MAStARI data extraction tool [112] to capture descriptions of participant and intervention

characteristics as well as relevant outcomes including descriptive statistics, performed

statistical tests, and p-values. A statistician was consulted to validate the extraction and

reporting. The first author of one article was contacted because of an inconsistency between

the text and a table, and a correction was made [124].


40

Data analysis

The studies presented considerable heterogeneity on several counts: The participants’ health

conditions (one pre-specified diagnosis or multiple chronic health issues), their living

arrangement (living alone or with someone), the focus of the outcome measures used to assess

occupational performance (pre-specified activities or self-identified performance problems),

the timing of post-intervention reassessments (first assessment 2.5 to 6 months after baseline

and second assessment, if any, after 6 to 12 months after baseline), and the reporting of the

statistical analyses. The data analyses and presentations were adapted to this situation. Results

were presented separately for three major diagnostic groups: stroke, Parkinson’s disease, and

multiple, chronic health issues. Effectiveness was defined as statistically significant between-

group differences in occupational performance in favour of an intervention group. Short-term

effectiveness was defined as measured immediately after the end of the OT intervention and

up until (but not including) 6 months post OT. Long-term effectiveness was defined as

effectiveness measured at least 6 months post OT. The results were summarised in narrative

presentations, supplemented by tables [112, 125]. It would have been preferable to conduct a

meta-analysis [125], yet this was not deemed feasible due to the heterogeneity among the

studies.

3.4. Intermediate analysis between Stage 1 and Stage 2

The intermediate analysis between the first and the second stage of the PhD study (see Figure

2) was performed to specify the qualitative research questions to be addressed in the second

stage of the PhD study. The analysis built on outcomes and process findings from the first two

studies, including the results from a post hoc analysis of the COPM data from Study I

showing that in the ICC-OT group, improvement in occupational performance had diminished

statistically significantly from the end of the OT intervention (the 3-month assessment) to the

6-month assessment. Finally, qualitative findings about older adults’ experiences with

processes and outcomes of home-based OT found during the literature search in Study II were

entered into the analysis [41-43]. A matrix was set up, the abovementioned sources were

scrutinised, and findings pertaining to processes and outcomes of home-based, client-centred,

and occupation-based OT were entered into the matrix. The matrix is found in Appendix 4.


41

The thematic analysis showed that older adults could achieve short-term improvements in

occupational performance during home-based, client-centred, and occupation-based OT

[2,65,118,121,122,124], yet in studies where short-term effects were measured twice, the

effects had in some cases diminished between assessments [2,124]. Only a few articles in the

literature review reported long-term effectiveness, and they showed that problems existed

concerning maintenance of the short-term improvements concerning self-care and

productivity [119,122]. A lack of knowledge was also identified regarding older adults’

experiences with their occupational performance after home-based OT, including which

strategies they may have found useful to deal with their daily occupations and persistent

performance problems. Likewise, there was a lack of knowledge about what older adults may

expect concerning their future performance after home-based OT. The intermediate analysis

resulted in some generalised questions that could be addressed in a qualitative study to

increase our understanding of older adults’ occupational performance after they have had

home-based OT (Appendix 4), and from these, the research questions addressed in Study III

were refined to:

1) How do older adults who have received home-based OT experience their occupational

performance post OT?

2) What do older adults who have received home-based OT expect concerning their

occupational performance in the future?

3.5. Methods, Study III

Study III was a qualitative study with 11 semi-structured interviews analysed in accordance

with inductive qualitative content analysis [79,80].

Population

To answer the research questions and to develop ideas to optimise home-based OT in the

future, I included a diverse study group of older adults from different parts of the country,

who would be able to tell about their experiences after having participated in somewhat

different ‘real world’ approaches. To add to the diversity in the study group, I broadened the

inclusion criteria from Studies I and II to include older adults who had been hospitalised


42

before they had home-based OT. Inclusion criteria for Study III and considerations

concerning personal features of the participants as well as characteristics of the OT

intervention received are presented in Table 3.

To ensure that the older adults had received a client-centred approach, it was an initial wish to

include older adults who had received OT where the COPM had been used. This turned out

not to be feasible: the COPM was well known but not consistently used by occupational

therapists in the municipalities. Instead, the managers of OT services confirmed that their

occupational therapists set goals in collaboration with the older adults and sought to

accommodate what they would like to work on. To ensure that the older adults had received

an occupation-based approach, it was an inclusion criterion that the OT had supported their

engagement in activities for a period of at least 3 weeks with the aim of improving

occupational performance, and that activities were practised as a major part of the

intervention. It was decided to interview the older adults 2 to 12 weeks after the OT had

ended. This was the result of a trade-off between a wish to talk to older adults who had had a

chance to implement in their everyday lives what they worked on during OT, while at the

same time ensuring that they could still remember some details from the intervention.

Table 3. In‐ and exclusion criteria for Study III [4]

Population

Age 65+

Living in a private home or sheltered (senior) housing.

Experiencing chronic health issues due to illness, disabilities, injuries, or general ageing processes.

At the time of referral to OT, the participant experienced problems that hampered his/her

occupational performance and independence in everyday life.

Danish speaking and able to tell about her/his present occupational performance in relation to

home‐based OT.

Exclusion criteria were alcohol or drug abuse, dementia or severe intellectual disability, tetraplegia,

and rapidly progressive diseases such as cancer or motor neuron disease.

Intervention

The older adult should have received home‐based OT with the following characteristics:

Planned and executed by a registered occupational therapist employed in a Danish municipality.

Minimum duration 3 weeks; The OT intervention was to be ended 2–12 weeks before the interview.

The OT was occupation‐based and client‐centred. Necessary assistive devices and minor home

adaptations had been introduced in relation to the occupations worked on.

Excluded were participants who had received OT with a main focus on provision of assistive devices

or home modifications without a specific focus on practicing activities. Excluded were also

participants who had mainly received OT at a municipal rehabilitation centre or at a hospital.


43

Sampling

Purposeful sampling was used [126,127], aiming for maximum variation concerning the

features, age, sex, living arrangement, need for assistance, and referral route. This contributed

to the richness of data, since older adults with different backgrounds and health situations

shared different experiences about their outcomes from OT, and about their strategies to

improve, maintain, or otherwise deal with performance problems post OT. They also had

different expectations about their future occupational performance. Managers of OT services

in 19 municipalities, representing rural and urban areas of different regions, undertook the

sampling. After inclusion of five participants, the procedure was adjusted, as I urged the

managers to try to include older adults with some of the features less prominent in the first

part of the sample. This led to a wider age span among the included participants and to a

sample with more males, married participants, participants who received daily self-care

assistance, participants who did not receive any assistance at all, and participants who had not

been hospitalised immediately before the home-based OT. When 11 older adults were

included and interviewed, I found the sought-for variance covered and a sufficient amount of

rich (detailed and nuanced), and thick descriptions (of sufficient quantity) produced to

proceed to the analysis [127].

Data collection

A semi-structured interview guide was composed to ensure that all the themes important to

answer the interview questions were approached, yet without impeding the older adults’ free

accounts of their experiences [79,126]. Hence, five primary interview questions covered how

the older adults experienced their occupational performance post OT and what they expected

regarding their occupational performance in the future:

Will you tell me about what happened when you had occupational therapy in your home?

Did you gain something from having occupational therapy?

Will you tell me about your present everyday life, now that the occupational therapist

does not come any more?

Will you tell me if something is now helping you or making it harder for you to do the

things you would like to do in your everyday?

Will you tell me about what you think it will take for you to continue doing the things

you like to do in your everyday?


44

The validity of the interview guide was strengthened through discussions among all involved

authors, and through two pilot interviews that led to minor revisions of the format (some more

possible follow-up questions were outlined) and wording. No professional language was used

in the guide or during the interviews (e.g. ‘activities’, ‘performance problems’ or ‘strategies’),

yet, due to the research questions, interest was naturally shown in what the older adults did or

did not do during their everyday life, how they did it, and what they expected concerning their

future doing or not doing.

In the data collection process, I aimed at obtaining rich and thick descriptions by performing

sufficiently long and detailed interviews and by asking for various examples of the older

adults’ experiences [127]. I engaged the older adults and captured their experiences and views

by encouraging them to describe in detail how they acted and what they felt [79,128]. By

asking questions in more and more detail, I got closer to understanding the older adults’

individual experiences of their occupational performance and their feelings, values, and

strategies, which contributed to a precise picture of what I intended to investigate and thus

strengthened the validity of the findings [79,128]. My experience from working as an

occupational therapist in older adults’ homes and my theoretical assumptions concerning

occupational performance including the PEO model [19,21,23,40,129,130] helped to enable

new perspectives to emerge through follow-up questions. For example, personal,

environmental, and performance components could be further examined. While performing

the interview, I used the interview guide and myself as instruments for data collection, and the

older adults’ accounts were products of our interaction [79,82]. Still, I challenged my

preconceptions and reached new levels of understanding [81].

Data analysis

The 11 interviews were transcribed verbatim; this resulted in 277 pages of text. These texts

were analysed using inductive qualitative content analysis [80,131,132], which is ‘a method

of describing the meaning of qualitative material in a systematic yet flexible way when

dealing with rich data that requires interpretation’ [80 p.1-5]. The inductive qualitative

content analysis was performed in five steps.

The first step was reading all the material to gain an overall impression.

In the second step, a data-driven coding frame was built consisting of 21 codes that covered

positive and negative outcomes from OT, consequences of these outcomes, strategies used


45

during and after OT, as well as expectations and strategies in relation to future occupational

performance. The inductive, or data-driven, approach was chosen because the aim of the

study was to elicit the older adults’ own experiences. The approach enabled the description of

aspects of the older adults’ experiences that might not have emerged had a concept-driven

coding frame been used, because the data contained more information than anticipated [80

p.87]. For instance, the codes ‘Untrained activities improved’ and ‘Negative consequences of

improved performance’ would not have been formulated beforehand, and the codes

concerning the different strategies that the older adults used or expected to use in the future

would not have been as many and as detailed should they have been formulated beforehand. I

chose to use my professional language when naming the codes, e.g. the terms ‘occupations’

and ‘strategies’ were used [80] because the aim of the study was to provide descriptions and

ideas to be used by occupational therapists. However, all authors were involved in the

development of the coding frame [80], and our different perspectives, partly due to the fact

that we had different professional backgrounds, added to the face validity and reliability of

the final version. Thus, we found that the coding frame accommodated an analysis of older

adults’ experienced occupational performance post OT and their expectations concerning their

occupational performance in the future, and that it would lead to a consistent data extraction

[80]. I performed a trial coding of parts of the material with one of the co-authors, and coding

practices were further specified to improve reliability and content validity [80 p.6]. For

instance, in the case of an older adult who experienced that the same performance problem

(driving a powered wheelchair) had improved (she could drive better indoors than before she

had OT) and was unresolved (she was still not able to drive independently outside), we

specified that to capture her experiences, two codes should be used: ‘Improved performance

related to OT aims’ and ‘Unresolved performance problems related to OT aims’.

In the third step, all material was coded, using the qualitative data analysis software NVivo

[133], which helped to maintain an overview of the procedure and to ensure transparency of

the process.

In the fourth step, the codes were categorised into nine subcategories and summarised into

three descriptive main categories: ‘Achieved improvements in occupational performance

through OT’, ‘Unresolved performance problems related to the OT intervention’, and ‘Efforts

to maintain occupational performance in the future’.


46

Finally, the fifth step (the interpretive level) concerned looking for patterns and co-

occurrences, which resulted in two explanatory syntheses: ‘The importance of achieving and

maintaining independence’ and ‘Strategies used to improve and maintain occupational

performance’. The coding frame is presented in Table 8 in the results chapter.

To further ensure the validity of the analysis, all authors discussed the interpretation of the

findings [80].


47

3.6. Ethical issues, Studies I, II, and III

Laws and regulations according to the Declaration of Helsinki were followed in all studies;

special attention was drawn to consent and confidentiality [134]. The Scientific Ethics

Committee of Central Denmark Region deemed that Study I and Study III did not to fall

under the category biomedical research, and further ethical approval was therefore not

required (Study I: Query number 153/2012, Study III: Query number 12/2017). All

participants were informed about the study and their rights orally and in writing and gave

written consent to participate. Studies I and III were approved by the Danish Data Protection

Agency (Study I trial identifier J.nr. 2012-52-0049, Study III trial identifier J.nr. 2017-41-

4995). Conduction of a literature review like Study II does not in itself warrant an ethical

approval. During the examination of the included studies, it was assured that ethical

considerations were appropriately dealt with, abiding international convention [134].

When conducting the study in the Danish municipalities, where a large proportion of the

participating older adults were receiving municipal services such as home care, it was

especially important to secure that information achieved by occupational therapists and

researchers during the interventions, assessments, and interviews was not transferred to the

authorities who had decisive power concerning the services offered to the older adults. It

could have hampered the open and trustful interaction between participants and professionals

during interventions and assessments and thereby the validity of the findings if there should

be any fear among the older adults that information about achieved improvements would be

automatically followed up by a cut in services. Therefore, although Danish municipalities

have well-developed electronic systems for filing and retrieving case-notes from rehabilitative

interventions, all information and assessed outcomes generated especially for study purposes

in Study I were kept confidential and separate from central electronic systems.

Conducting qualitative interviews called for some ethical considerations concerning the

power relation between me as the interviewer and the older adults as interviewees [79]. The

qualitative interview is a one-way, instrumental dialogue, and it is an ethical responsibility of

the interviewer not to let it become a manipulative dialogue [79]. I was much aware of this

during the interview. I showed respect for the older adults and exhibited openness towards

unexpected phenomena, and through briefing and debriefing I made sure that the older adults

knew their rights during and after the interview [79]. After the interview, I asked how it had


48

been to participate and thus gave the older adults a possibility of talking freely with me about

how it had been to be interviewed and how they felt afterwards. They generally expressed that

it had been nice to participate and to share their experiences and thoughts about the future.

To render the results of research open to the public is a moral imperative for the researcher,

since if we fail to publish data, the data will perish, the knowledge will not be used, and the

investments in research will be lost [135]. I complied with recognised standards of reporting:

The Consolidated Standards of Reporting Trials (CONSORT) and the Template for

Intervention Description and replication (TIDieR) checklists [136,137] for Article1

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)

checklist [115] for Article 2

The Consolidated criteria for reporting qualitative research (COREQ) checklist [138]

for Article 3

The guidelines helped me follow the traditions of reporting within each area of research and

to achieve transparent and complete reporting.

3.7. Registration

Study I was registered through Current Controlled Trials, trial identifier ISRCTN93873801

DOI 10.1186/ISRCTN93873801 [139].

4. RESULTS AND FINDINGS

49


This chapter falls into two parts.

Firstly, quantitative results and qualitative findings concerning the outcomes of home-based,

client-centred, and occupation-based OT are presented, building on all three studies. The first

time a study is introduced, information is given in text and tables to describe the participants

and the main results or findings.

Secondly, findings concerning therapeutic approaches and strategies to improve occupational

performance are presented, building on all three studies. The findings are merged and

presented in a joint table.

4.1. Outcomes of home‐based, client‐centred, occupation‐based OT

Results from Study I about effectiveness of home‐based OT for older adults with

multiple chronic health issues

Study I tested the effectiveness of home-based ICC-OT compared to usual practice [2]. The

ICC-OT group and the Usual-Practice group did not differ on demographics and baseline

assessments. The total loss to follow-up at 3 months was 18%, and at 6 months, it was 22%.

The proportions of participants lost to follow-up were not statistically significantly different

between the two groups at 3 months (chi-square test: p = 0.21) or at 6 months (chi-square

test: p = 0.35).

Table 4 gives an overview of demographics and baseline assessments for those participants

who were reassessed and those who were not reassessed at 3 months. Those who were not

reassessed at 3 months had somewhat poorer general health (SF-36 GH score) than those who

were reassessed, and in the Usual-Practice group this difference was statistically significant

(difference 20.4, t-test: p = 0.007).


50

Table 4. Demographics and baseline assessments. Older adults reassessed and not

reassessed at 3 months. Study I Mean (SD) when not otherwise reported

ICC‐OT reassessed at 3 months n = 46 (out of 59)

Usual Practice reassessed at 3 months n = 53 (out of 60)

ICC‐OT not reassessed at 3 months n = 13

Usual Practice not reassessed at 3 months n = 7 (COPM: 8)

Age 78.3 (9.2) 77.0 (6.9) 78.6 (10.4) 75.3 (6.1)

Women, n (%) 34 (74%) 35 (66%) 11 (85%) 6 (86%)

Living alone, n (%) 38 (83%) 42 (79%) 11 (85%) 6 (86%)

1 diagnosis, n (%) 13 (28 %) 16 (30 %) 7 (54%) 2 (29%)

2 diagnoses, n (%) 26 (57 %) 28 (53 %) 2 (15%) 5 (71%)

>3 diagnoses, n (%) 7 (15 %) 9 (17 %) 4 (31%) 0 (0%)

Personal care/ practical help, n (%) 36 (78 %) 43 (81 %) 10 (77%) 6 (86%)

Meal delivery, n (%) 13 (28 %) 9 (17 %) 3 (23%) 3 (43%)

COPM performance 3.42 (1,10) 3.48 (1.26) 3.12 (1.25) 2.89 (1.1)

COPM satisfaction 3.78 (1.60) 3.39 (1.45) 3.58 (1.41) 3.25 (1.42)

AMPS motor 0.55 (0.64) 0.68 (0.63) 0.65 (0.66) 1.06 (0.57)

AMPS process 0.59 (0.35) 0.71 (0.36) 0.71 (0.34) 0.68 (0.21)

SF‐36 GH# 47.4 (18.4) 44.0 (18.2) 36.2 (23.3) 23.6 (16.18)

SD: standard deviation. COPM: Canadian Occupational Performance Measure. AMPS: Assessment of Motor and Process Skills. SF‐36: Short Form 36 Health Survey. # Standardised general health score, range 0‐100, better score denotes better general health. ICC‐OT: intensive client‐centred occupational therapy.

The older adults in the ICC-OT group received an average of 15 home visits by their

occupational therapists. A broad array of activities was worked on. Typical activities were

dressing, bathing, grocery shopping, functional mobility, cleaning, cooking, laundry, hobbies,

walks, and visiting friends. Similar amounts of self-care (32%), productivity (39%) and

leisure activities (29%) were addressed. In the Usual-Practice group, 14 older adults received

OT as part of home-care reablement the first 11 weeks. They had on average 3.1 hours of OT;

it was not documented which activities were addressed.

Occupational performance measured on the COPM, primary hypothesis

The primary hypothesis was confirmed. Thus, the ICC-OT group improved their COPM

performance scores statistically significantly more than the Usual-Practice group from

baseline to 3 months (difference in change 1.26 (95% CI 0.50;2.02) p = 0.001). The same was

the case from baseline to 6 months (difference in change 0.98 (95% CI 0.27;1.70) p = 0.008),

see Table 5.


51

Table 5. Occupational performance: within‐group changes and between‐group differences in change. Study I Within‐group changes

ICC‐OT (59 at baseline)

Within‐group changes Usual Practice (60 at baseline)

Between‐group differences in change

Assess‐ment^

Change baseline to 3 months¤ (SD) COPM n = 46 AMPS n = 36




Difference in change baseline to 3 months ۩ (95 % CI)

Difference in change baseline to 6 months۩ (95 % CI)

COPM Perfor‐mance

1.87 *** (SD 1.84)

1.42*** (SD 1.91)

0.61* (SD 1.94)

0.44 (SD 1.55)

1.26 (0.50;2.02) p = 0.001

0.98 (0.27;1.70) p = 0.008

COPM Satisfac‐tion

1.83*** (SD 2.06)

2.08*** (SD 2.11)

1.12*** (SD 1.97)

0.99*** (SD 1.82)

0.71 (‐0.09;1.52) p = 0.08

1.09 (0.28;1.90) p = 0.009

AMPS Motor

0.33* (SD 0.82)

0.44*** (SD 0.68)

0.28* (SD 0.74)

‐0.00 (SD 0.62)

0.05 (‐0.30;0.39) p = 0.79

0.44 (0.14;0.74) p = 0.005

AMPS Process

0.17 (SD 0.53)

0.17* (SD 0.49)

0.07 (SD 0.51)

‐0.02 (SD 0.42)

0.11 (‐0.13;0.34) p = 0.37

0.19 (‐0.02;0.40) p = 0.08

^Range, all assessment tools: higher scores are more positive. COPM: Canadian Occupational Performance Measure. AMPS: Assessment of Motor and Process Skills. ICC‐OT: intensive client‐centred occupational therapy. ¤Paired t‐tests. SD: standard deviation. ۩ Unpaired t‐tests. CI: confidence interval. The results were statistically significant at 0.05*, at 0.01**, or at 0.001*** level.

The exploratory analyses concerning within-group changes showed that at both 3 and 6

months, the ICC-OT group scored statistically significantly higher on COPM performance

than at baseline. The Usual-Practice group also scored statistically significantly higher on

COPM performance at 3 months than at baseline; however, this was not the case at 6 months

(Table 5).

The COPM performance scores at baseline, at 3, and at 6 months are illustrated in Figure 6.

The figure is based on the 90 participants who were assessed on the COPM at all three points

of time. The decrease in the ICC-OT group from 3 months to 6 months was 0.49 points (95 %

CI 0.05;0.93). This was statistically significant, t-test, p = 0.029. There was no significant

change from 3 to 6 months in the Usual-Practice group (0.00 points, 95 % CI -0.46;0.46, p =

0.95).


52

Figure 6. COPM performance scores at baseline, 3, and 6 months. Study I

As change in COPM performance from baseline to 3 months was the primary outcome,

explorative analyses were performed to see whether age, sex, or general health at baseline

modified the effects of the intervention assessed on the COPM performance scale. This was

not the case concerning the variables age and sex; details are found in Article 1 [2]. In

contrast, general health at baseline tended to modify the between-group difference in change.

Figure 7 illustrates the effect of the older adults’ perceived general health at baseline (their

SF-36 GH score) on the change in COPM performance from baseline to 3 months. The

different directions of the slopes indicate that general health at baseline tended to modify the

between-group differences in change on COPM performance, yet the slopes were not

statistically significantly different, multiple linear regression analysis: p = 0.073. The

between-group difference in change in COPM performance among the older adults with an

SF-36 GH score from 50 and up (n = 39) was 2.11 points (95% CI 0.92;3.31). Among the

older adults with an SF-36 GH score below 50 (n = 59), the difference was only 0.59 points

(95 % CI -0.42;1.60). However, the differences in change between older adults with higher

and lower SF-36 GH score were not statistically significant, multiple linear regression

analysis: p = 0.057.

0

2

4

6

Baseline 3 months 6 months

COPM performance scores

ICC‐OT n = 44 Usual Practice n = 46


53

Figure 7. The influence of health status on change in COPM from baseline to 3 months. Study I

Of the 21 older adults who did not have a COPM assessment at 3 months, 13 (62%) declined

with reference to health issues (Figure 3). Seen in the light of the exploratory analysis of the

influence of general health on change in the COPM performance score from baseline to 3

months (Figure 7), a single value imputation of COPM performance change scores was

performed as explained in the methods chapter. The estimated between-group differences of

change at 3 months, when imputations had been made, were from 1.14 to 1.21. Overall, the

post hoc analysis suggested that the between-group difference was, at the most, 0.12 points

smaller than the difference of 1.26 points found in the primary analysis. Hence, this did not

change the overall conclusions.

Satisfaction with occupational performance, measured on the COPM

At 3 months, there was no statistically significant between-group difference in change in

COPM satisfaction. At 6 months, however, there was a statistically significant difference in

favour of the ICC-OT group. Within both groups, COPM satisfaction was statistically

significantly higher at 3 and at 6 months than at baseline. (Table 5).

-4-2

02

46

0 20 40 60 80 100SF-36 GH score at baseline

Usual Practice n=46 (dotted) ICC-OT n=52 (solid)


54

Quality of occupational performance, measured on the AMPS motor and

process scales

At 3 months, there was no statistically significant difference in change between the two

groups concerning the AMPS motor scores. At 6 months, however, there was a statistically

significant difference in favour of the ICC-OT group (Table 5). Concerning within-group

changes, the ICC-OT group scored statistically significantly higher on AMPS motor at both 3

and 6 months than at baseline. The Usual-Practice group scored statistically significantly

higher on AMPS motor at 3 months than at baseline; at 6 months, their improvements were

lost again (Table 5). Concerning the AMPS process scores, there were no statistically

significant between-group differences in change after either 3 or 6 months (Table 5).

Results from Study II about effectiveness of home‐based OT for older adults

with multiple chronic health issues

Study II reviewed scientific evidence concerning the effectiveness of home-based OT on

older adults’ occupational performance [3]. The systematic literature review included eight

articles reporting six RCTs. In this results chapter, I have chosen to focus on the three articles

reporting studies that included older adults with multiple chronic health issues, because these

participants resemble those in Study I and Study III concerning the complexity of problems

and the mix of participants. The three articles report two studies that took place in the United

States and in Belgium [65,122,123]. It was concluded that the OT had been occupation-based,

because the intervention aims pertained to occupational performance, and because active

engagement in activities was the primary component of the assessments and interventions.

Details about purpose, design, participants, OT interventions, and outcomes are shown in

Table 6. Further details are found in Article 2 [3].


55

Table 6. The effect of OT on occupational performance of older adults with multiple chronic health issues. Study II (adapted from [3])

Author/Country/Year

/Purpose

Design

Participants

OT interventions in experimental groups and control groups

Outcomes: Assessment#/Results*

Gitlin et al. [122,123] USA, 2006+2008 The purpose was to test the efficacy of an OT intervention to reduce functional difficulties, fear of falling and home hazards; and to enhance self‐efficacy and adaptive coping [122] Subgroup analyses explored whether some groups benefited more than others [123]

RCT 2 groups: Occupation‐based OT vs. Control Mean age 79 years N = 300 at 6 mths N = 285 at 12 mths

Intervention: Cognitive, behavioural and environmental strategies were practised through occupation: problem solving, energy conservation, safe performance and fall recovery, home modifications and training in their use. Goal setting: not mentioned, but interventions focused exclusively on areas reported as problematic by the older adults Time: 6 months, mean five OT sessions of which one was a telephone contact Reinforcement btw. 6 and 12 months: three telephone calls + final home visit Control group: no intervention

Self‐care (ADL Index): Short term 6 mths after baseline: OT group benefited the most Diff. btw. groups ‐0.13 (no CI), ANCOVA p=0.03 >80‐year‐olds and women benefited the most at 6 mths Long term 12 mths after baseline: No difference >80‐year‐olds benefited the most at 12 mths Productivity (IADL Index): Short term 6 mths after baseline: OT group benefited the most Diff. btw. groups ‐0.14 (no CI), ANCOVA p=0.04 Long term 12 mths after baseline: No difference

De Vriendt et al. [65] Belgium, 2015 The purpose was to examine the effectiveness of a client‐centred and activity oriented intervention with the main focus on improving basic ADL

RCT 2 groups: Occupation‐based OT vs. Control Mean age 80 years N = 168 at 10 weeks

Intervention: A client‐centred, tailored to the needs of the person and activity oriented program. Training of functional skills, advice and instruction in use of assistive devices, education of caregiver Goal setting: client‐centred goals and negotiation of therapy plan Time: 10 weeks, mean 1.9 OT sessions Control group: Usual care: community services (both groups could have usual care)

Self‐care (b‐ADL scale): Short term 2.5 mths after baseline: OT group benefited the most Diff. btw. groups 6.7 (95% CI 1.4;12.1). ANCOVA p=0.001 No long‐term follow‐up

Further details about the participants are found in Paper 2 [3]. OT=Occupational therapy, ADL=Activities of Daily Living, IADL=Instrumental Activities of Daily Living, RCT =Randomized controlled trial, N=Number analysed, mths=months, #Only assessments of occupational performance are reported, *Only statistically significant results are reported in detail, b‐ADL=Basic activities of daily living‐scale, CI=confidence interval.


56

In the study performed by Gitlin et al. (N = 300), the participants reported an average of seven

chronic health conditions (orthopaedic/musculo-skeletal, medical, and sensory). They had

difficulties within self-care and productivity, but they did not receive formal help [122,123].

In the study performed by De Vriendt et al. (N = 168), the participants were categorised as

‘frail’, and had on average 6.6 chronic health conditions (no further diagnostic details were

reported). They had difficulties with one or more self-care activities [65], and 67% received

care provided by a nurse.

The intensity of the interventions and the timing of assessments differed between the studies.

In Gitlin’s study, four home-based OT sessions and a telephone session were delivered over 6

months, followed by a reinforcement initiative including three telephone calls and a home

visit. Two assessments were performed post OT: 6 and 12 months after baseline [122]. Thus,

both short- and long-term effectiveness was reported. In the study by De Vriendt et al., an

average of 1.9 home-based OT sessions were delivered over 10 weeks [65]. Only short-term

effectiveness was reported, assessed at the end of the OT intervention.

In both studies, self-care (ADL) was an outcome, and home-based OT was effective in the

short term: the intervention groups benefited statistically significantly more than the control

groups [65,122]. Only Gitlin had included a long-term follow-up. At 12 months (6 months

after the OT intervention), there was no statistically significant difference between the groups

concerning self-care [122].

Productivity (IADL) was another outcome in Gitlin’s study. The intervention was effective in

the short term: the intervention group benefited statistically significantly more than the

control group. At 12 months (6 months post intervention), there was no statistically

significant difference between the groups concerning productivity [122].

Gitlin’s second article reports subgroup analyses exploring who benefited the most from the

OT intervention. Reported here are findings concerning age and sex. In the short term,

participants above 80 years old and women benefited the most on self-care activities (ADL).

Over the long term, participants above 80 years old still benefited the most concerning self-

care activities. No significant subgroup differences were found concerning productive

activities (IADL). No subgroup analyses were performed concerning health status [123].


57

Results from Study III: Outcomes of home‐based OT experienced by older adults

with multiple chronic health issues

The qualitative study sought to determine older adults’ experiences of their occupational

performance after OT and their expectations concerning their occupational performance in the

future. The 11 older adults who participated in the study are presented in Table 7. They

experienced various health issues, and eight (73%) had received home-based OT after a

hospitalisation. The older adults had received OT in their home over 1 to 9 months. The home-

based OT had included practising activities within self-care, productivity, and leisure. The older

adults had practised one to seven specific activities with their occupational therapists, yet they

had also discussed and received advice on other problems.

Table 7. Demographic and self‐reported clinical data of the participants in Study III

Demographic and clinical data N = 11

Females Males

9 (82%)2 (18%)

Mean age (SD) 70 to 79 years 80 to 89 years 90 to 99 years

85 (6.38) 2 (18%) 7 (64%) 1 (18%)

Living alone

9 (82%)

Health issues* Mean number 3.5 Orthopaedic/musculoskeletal Medical problems Sensory (hearing loss, pain) Fatigue Neurologic

14 9 7 5 4

Self‐care, daily assistance** Housekeeping assistance***

2 (18%)8 (73%)

Referral to home‐based OT From hospital From municipality

8 (73%) 3 (27%)

SD = standard deviation. *Health issues influencing occupational performance (reported by the older adults and later categorised acc. to the AMPS manual [95]). **Home care. ***Home care, family, others.

The inductive qualitative content analysis resulted in the coding frame shown in Table 8. For the

following presentation, references are, for clarity, given for the code numbers in the table.


58

Table 8. Research questions, categories, and codes. Coding frame developed in Study III

Most participants in Study III had to some degree improved their occupational performance

during home-based OT (Code 1). Improvements were experienced within self-care, indoor and

outdoor mobility, productivity, and leisure.

Research questions

Subcategories and codes Main categories

How do older adults who have received home‐based, client‐centred, and occupation‐based OT experience their occupational performance post OT?

Improved occupational performance 01) Improved performance related to OT aims 02) Untrained activities improved

Achieved improvements in occupational performance through OT Strategies adopted through OT that enhance occupational

performance today 03) Adaptation of activities 04) Assistive devices and environmental adaptations 05) Problem solving

Consequences of improvements in occupational performance achieved through OT 06) Feelings of independence or freedom 07) Feelings of joy related to resumed occupations 08) Feelings of safety or comfort 09) Experiences of positive social impact 10) Negative consequences of improved performance

Unresolved performance problems related to OT aims 11) Unresolved performance problems

Unresolved performance problems related to the OT intervention Consequences of unresolved problems

12) Feelings of unhappiness

Strategies adopted to deal with the unresolved problems 13) Accepting the situation 14) Receiving help 15) Working to improve occupational performance

What do older adults who have received home‐based, client‐centred and occupation‐based OT expect regarding their occupational performance in the future?

Thoughts and feelings concerning future occupational performance 16) Confidence concerning future performance 17) Worries concerning future performance

Efforts to maintain occupational performance in the future

Strategies used to maintain occupational performance18) Continuing with important occupations 19) Keeping physically and mentally fit

Strategies to deal with decline20) Adapting to decline 21) Knowing whom to contact


59

Untrained activities in some cases improved, too (Code 2). The improvements were in most

cases highly valued and linked to feelings of independence, joy, safety, or comfort (Code 6-8).

The improvements also had positive social consequences , and examples were given how one

could visit the family, take up walks with a friend, or meet acquaintances in the supermarket

again (Code 9).

When independence was achieved, it could imply that the home-care assistant stopped. While

this could be experienced as positive, for instance, because one did not have to sit and wait for

the help in the morning any more (Code 6), it could also have negative connotations (Code 10).

Some problems within self-care, mobility, productivity, and leisure had not been solved during

OT (Code 11). These problems were linked to persistent tiredness, pain, or impaired mobility,

and feelings of unhappiness, helplessness, and a lack of dignity were expressed (Code 12).

Summary of outcomes of home‐based, client‐centred and occupation‐based OT

All in all, Study I and Study II showed that home-based OT has potential to improve older

adults’ occupational performance [2,3]. At the end of the interventions, the improvements were

all in favour of the intervention groups and statistically significant, yet in Study I, some of the

improvements were lost in the ICC-OT group 3 months after the end of the intervention (at the 6-

month assessment). Long-term effectiveness was only explored in one of the two RCTs among

older adults with multiple chronic health issues in Study II; the improvements in self-care and

productivity were no longer statistically significant 6 months after the end of the intervention.

Effect modification was explored in Studies I and II with contrasting results. In Study I, age and

sex were shown not to modify the effect of ICC-OT, while in Study II, the article by Gitlin et al.

showed that participants above 80 years of age and women benefited the most [122]. In Study I,

older adults with better health tended to benefit more than those with worse health; such an

association was not explored by Gitlin et al.. Study III showed that older adults valued the

improvements achieved through home-based OT and how the improvements affected their

everyday lives. Nevertheless, becoming independent of help could be perceived as positive as

well as negative. Furthermore, unresolved problems were linked to feelings of unhappiness,

helplessness, and lack of dignity.


60

4.2. Therapeutic and personal strategies to deal with performance problems

By merging and synthesising the findings from the PhD study and building on OT theory, I

developed an evidence- and theory-based chart of approaches and strategies to guide

occupational therapists to tailor individual programmes for older adults who need OT to improve

or maintain their occupational performance or to deal with persistent performance problems.

From Study I, the applied therapeutic strategies were derived from the description of the

intervention (Figure 4), and from client records. From Study II, therapeutic strategies were

derived from the methods sections of the RCT articles referred to in the beginning of this chapter

[65,122]. From Study III, strategies are based on the interviews and to a minor degree on

information from the municipal managers of OT. The strategy chart is presented in Table 9.

During the development of the strategy chart, it became clear that some therapeutic approaches

were generally used; they were linked to client-centred and occupation-based OT. In addition,

two different sets of more specified strategies emerged pertaining to whether the aim was to

improve and maintain occupational performance, or to deal with performance problems that

could not be resolved in ways that fully met the goals and aspirations of the older adults. In

consequence, the strategy chart has three headings: General therapeutic approaches, Strategies to

improve and maintain occupational performance, and Strategies to deal with persistent

performance problems.

General therapeutic approaches

Common for all three studies was the use of general client-centred and occupation-based

therapeutic approaches, including goal setting, negotiation of therapy plan, tailoring strategies to

the individual, and practising activities, known from OT professional practice models [19,21].

While these general therapeutic approaches were inherent in the specific type of OT under study,

the older adults in Study III had clearly also adopted practising activities as a personal strategy

after the OT intervention had ended. They practised the activities worked on during OT to a high

degree and expressed strong wishes to further improve and maintain their occupational

performance (Code 15,18). They also expressed the importance of continuing doing what they

were used to do, which expands the understanding of ‘practising’ post OT.


61

Strategies to improve and maintain occupational performance

The lower parts of the strategy chart in Table 9 present the more specific therapeutic and

personal strategies to create changes within the person, the environment, and the occupation in

order to address specific performance problems. The structure of this part of the strategy chart is

inspired by the PEO model and by Polatajko et al., who have described how to effect change in

specific occupations and in occupational patterns by enabling the person, the environment, and

the occupation to change [23,40].

Many of the specific therapeutic strategies used during OT were assumed post OT as well, by the

older adults in Study III, in an attempt to further improve or maintain their occupational

performance. Therapeutic and personal strategies to improve and maintain occupational

performance are therefore presented jointly. The strategies pertained to changing personal

capacities, adapting physical surroundings, to social and societal support, and to adapting aspects

of occupation [40]. The strategies were often used in combination.

Changes within the person pertained to changing personal capacities. Some older adults from

Study III continued physical and cognitive training, for instance, by attending a municipal

rehabilitation centre or by arranging walks with friends, in anticipation that this would help them

to improve and maintain their occupational performance (Code 19). Some mentioned how they

had continued problem solving to adapt their activities (Code 5). Thus, they analysed the

problem, came up with ideas, and tried them out, and some expressed confidence that they could

also solve future problems in this way (Code 16).

Adapting the physical surroundings were fundamental parts of all the OT interventions in Study

I, II, and III. In Study I, more older adults in the ICC-OT group than in the Usual-Practice group

received assistive devices and/or minor home modifications the first 11 weeks (22 vs. nine, chi-

square test p = 0.006). While most of the environmental strategies accounted for in Study III

were perceived as useful by the older adults (Code 3,5), contrasting experiences were expressed

concerning the use of assistive devices. Learning to use reachers, rollators, stocking aids, etc. had

helped improve occupational performance during OT. This was positively accounted for by some

participants, and many still used assistive devices. Contrariwise, others would not accept using

assistive devices; either they had stopped using them post OT, or they had a strong wish to part

with them in the future (Code 4).


62

Examples of social and societal support strategies are the reinforcement initiative through

supplemental telephone contacts in the study by Gitlin et al. [122], and the finding in Study III

that it was nice to know how to contact the occupational therapist again, should need arise (Code

21). Furthermore, in the study by De Vriendt et al. the occupational therapists sought to involve

the patients’ social network, as caregivers were educated to support the older adults’

occupational performance [65], and in Study III, some older adults mentioned that having

binding appointments with others helped them to stay motivated and continue their activities

outside the home (Code 18).

Several specific strategies pertained to adapting aspects of occupation in order to improve

occupational performance. The strategies presented in Table 9 were often mentioned together.

Several older adults in Study III talked about how they could adapt activities to be performed in

a satisfying way, which could encompass several of the strategies in Table 9.

Strategies to deal with persistent performance problems

This presentation is based on Study III. As previously explained, some performance problems

persisted post OT. In addition, some older adults expressed fear that in the future more problems

would emerge that would not be easily solved (Code 17). The strategies used by the older adults

to deal with persistent or expected future performance problems spanned from giving up

performing certain activities all together to negotiating acceptable ways of performing the

activities, with or without help from others. As seen in the strategy chart in Table 9, the

strategies to deal with persistent performance problems pertained to changing occupational

patterns, changing physical surroundings, social and societal support, adapting aspects of

occupation, and abandoning existing occupation [40]. The strategies were often used in

combination.

Occupational patterns have been defined as ‘the regular or predictable way of doing’, and it

‘occurs when human beings organize activities and occupations’ [140]. The accounts of some of

the older adults in study III show how they worked on changing occupational patterns or

adapting former standards and habits and on accepting the performance of some activities less

often, less independently, or with less quality than they used to (Code 20). Some told how the

occupational therapist had helped them come to terms with persistent performance problems and

with accepting the receipt of help (Code 13,14).


63

Changing the physical surroundings by moving to a nursing home or sheltered housing was

expressed as a future strategy when adaptation would not be sufficient to solve the problems

pertaining to an unfit home environment (Code 20).

Social and societal support could pertain to receiving help to have specific chores done, typically

household chores or gardening, and this strategy was presently used and considered for the future

by the older adults in Study III (Code 14). Nevertheless, concerns were also expressed about

being too much of a strain on one’s spouse or family. Rather than receiving help and passively

watching things being done, several older adults said that they preferred and enjoyed performing

household chores together with a family member or a hired help (Code 14).

Occupations could be adapted to suit the older adult’s lower performance level, this could

include performing them less often or less independently than before, and in some cases, certain

activities were given up altogether (Code 20).


64

Table 9. Strategy chart. Approaches and strategies to deal with older adults’ performance problems General, therapeutic

approaches

Collaborating on goal setting (I, II, III)

Negotiating therapy plan (I, II, III)

Tailoring strategies to the individual (I, II, III)

Practising activities* (I, II, III)

Changes within

the person

Changes within

the environment

Changes within

the occupation

Strategies to im

prove

and m

aintain occupational

perform

ance

Changing personal capacities

Physical training (I, II, III)

Strategy training (I, II, III)

Cognitive training (II, III)

Problem solving (II, III)

Adapting physical surroundings

Assistive devices (I, II, III)

Home modifications (I, II, III)

Labour saving household devices (III)

Social and societal support

Additional contacts with occu‐pational therapist post OT (II, III)

Education of caregiver (II)

Binding appointments with others

to encourage occupational performance (III)

Adapting aspects of occupation

Conserve energy (I, II, III)

Reorganise performance sequences/change procedures (I, III)

Simplify activities (I, III)

Strategies to deal with

persistent perform

ance problems Changing occupational patterns

Change or adapt former habits

and standards (III)

Accept to perform activities less often, less independently, with

less perceived quality or not at all (III)

Come to terms with having to receive help (III)

Changing physical surroundings

Move to nursing home or sheltered housing (III)

Social and societal support

Get help to have

specific chores done (III)

Perform activities with others (III)

Adapting aspects of occupation

Adapt activities to be performed less often or less independently (III) Abandoning existing occupations

Give up performing certain

activities (III)

The roman numerals refer to findings from study I (RCT), II (Review), and III Qualitative study). * Practising activities was also

described as a personal strategy after the OT intervention had ended.

The table is inspired by [40].

5. DISCUSSION

65

5. DISCUSSION

The overall aims of the PhD study were to examine whether home-based, client-centred, and

occupation-based OT may help older adults to improve and maintain their occupational

performance, and to understand how older adults experience and deal with their occupational

performance post OT. A main result of the PhD study is that ICC-OT, which encompasses all

three abovementioned features, can effectively improve the occupational performance of older

adults in the short term. Another main result is a developed strategy chart with suggestions of

specific change strategies addressing the person, the environment, and the occupation with

two different aims: to improve and maintain occupational performance and to deal with

persistent performance problems.

5.1. Outcomes of home‐based, client‐centred, and occupation‐based OT

The primary hypothesis of Study I was confirmed: an intensive OT programme, the ICC-OT,

delivered over 11 weeks in a home-based, client-centred, and occupation-based fashion, could

effectively improve older adults’ self-reported occupational performance. In addition,

statistically significant improvements in self-reported occupational performance and

satisfaction, and in therapist-observed quality of performance 3 months after the end of the

OT intervention indicated that the strategies learned during OT had been successfully

generalised to daily occupational performance [2].

The results of Study I pertain to short-term effects of home-based ICC-OT among older adults

with multiple chronic health issues. The results are in concordance with conclusions from the

two studies included in Study II that were performed among older adults with multiple

chronic health issues [65, 122] and with three of the four studies included in Study II among

older adults with stroke or Parkinson’s disease [118,121,124]. While the effects in Study I,

due to the use of the COPM as primary outcome measure, pertained to the broad category of

self-identified performance problems, the effects in most of the articles in Study II were

assessed on predefined activities within self-care and productivity. However, the older adults

in Study I worked to a high degree on self-care activities, housekeeping activities, and

mobility, which overlaps greatly with the activities mostly addressed in the RCTs in Study II.

This suggests that the conclusions concerning study outcomes in Studies I and II refer to very

similar outcomes and that the studies together strengthen the evidence for effectiveness of

5. DISCUSSION

66

home-based, client-centred, and occupation-based OT for older adults with performance

problems due to multiple health issues.

Furthermore, the positive effects of home-based, client-centred, and occupation-based OT

found in Studies I and II are in concordance with results from other trials of home-based and

occupation-based OT. However, some of these studies had wider definitions of age groups

and referral practices, a higher degree of multidisciplinarity, and in some cases a narrower

scope concerning which performance problems could be addressed [16,17,56, 62].

The findings from Study III showed that improved occupational performance, achieved

through home-based, client-centred, and occupation-based OT, was generally highly valued

by older adults and related to improved independence, positive feelings of independence, joy,

safety, or comfort, and positive social consequences [4]. Similar findings have been reported

in other studies among older adults who had received OT in their home [41,42,74].

Thus, statistically significant results concerning effectiveness as well as qualitative findings

concerning older adults’ experienced outcomes, support provision of home-based, client-

centred, and occupation-based OT to older adults.

However, some negative consequences of improved occupational performance were also

present. They were related to the loss of human contact and encouragement [4]. A Danish

report that builds on interviews with older adults who had participated in rehabilitation taps

into the same issue. This report shows that older adults who felt lonely were, in general, less

interested in becoming independent. They feared they would be deprived of their home-care

assistants [9]. Such findings should not go unnoticed, and a special consideration should be

given to older adults who fear that improving their occupational performance may have

detrimental effects on their everyday life and wellbeing.

Looking further into the results in Study I revealed that the scores of the older adults in the

ICC-OT group declined statistically significantly on the COPM performance scale from the

end of the intervention (at 3 months) to the end of the study (at 6 months), although they, as

formerly mentioned, still fared better than the control group. A similar result was found in an

RCT among older adults with Parkinson’s disease included in Study II [124]. In contrast, the

scores in the ICC-OT group in Study I did not decline on the AMPS motor scale during the

same period. These differences align with previous research that has suggested that the self-

5. DISCUSSION

67

rated and the performance-based assessments do not assess the same thing [88-90]. A further

explanation of why self-rated performance may decline, while observer-based performance

improves may be sought in the future. Concerning long-term effectiveness measured at least 6

months post intervention, the articles included in Study II reported some positive [119,121]

but mainly negative results [119-122]. These results indicate a problem with long-term

maintenance of achieved improvements from home-based, client-centred, and occupation

based OT once the therapy is over, and similar trends have been reported in other studies of

rehabilitative interventions for older adults [67,141]. As we did not perform a long-term

follow-up in Study I, we do not know whether the ICC-OT, which was a more intensive

programme than those reported in Study II, led to better long-term effectiveness than the

interventions in Study II. However, the declines in self-reported performance the first 3

months post intervention in Study I suggest that serious consideration should be given to

which therapeutic strategies can be applied to support maintenance of achieved effects. Focus

could, for instance, be on teaching problem-solving strategies, and on how older adults can

generalise such strategies to their daily occupations post OT and transfer them to deal with

performance problems that emerge post OT [66,142].

In Study I, the ICC-OT was effective regardless of the older adults’ age or sex. The older

adults included in Study I had multiple health issues, and a large percentage already received

home care at baseline. Economic reports within Danish home-care reablement have pointed

out that new recipients of home-care services seem to have a better potential to improve their

occupational performance than those who have received help for a longer period of time

[143,144]. Contrariwise, a Danish experimental study of home-care reablement concluded

that receiving home-care services should not be considered a barrier to participation in and

achieved improvements from home-care reablement [145]. Lack of improvement may be

rooted both in a poor health condition and lack of energy but also in the fear of losing one’s

home help, as addressed earlier in this discussion. In the studies of home-care reablement,

older adults were not given the same degree of free choice of what to work on as they were in

Study I. Some of the success of the OT programme in Study I may pertain to the fact that the

older adults were allowed to also pursue goals that were not about the activities for which

they received home help.

A modifying effect of older adults’ general health at baseline was indicated in Study I, where

older adults with better general health, measured on the SF-36 GH scale, profited more from

5. DISCUSSION

68

the ICC-OT than those who rated their general health low, yet some older adults with low

general health also improved considerably. This interesting result deserves further attention in

future studies. Some older adults with many health issues may not have the surplus energy or

motivation needed to participate in interventions as intensive as ICC-OT, and they may not

have the same potential for improvement. Thus, an American study of home-based

rehabilitation showed benefits among older adults with moderate frailty but not among those

with severe frailty [146]. When older adults are considered for ICC-OT, they should therefore

be involved in determining whether they have the health and energy to enter such an intensive

programme. OT twice a week for 11 weeks may be too demanding for older adults with many

health issues. Their interventions should perhaps be less intensive than the ICC-OT, and the

aims should not necessarily be about improving occupational performance. Maintaining

occupational performance or enhancing occupational engagement would be worthy aims, too;

this is discussed further in section 5.2.

A health economic evaluation was not planned for Study I, and it was not feasible to perform

afterwards due to applied registry practices. In congruence with the OT theories and values

underlying the ICC-OT, its main aim was to improve older adults’ occupational performance,

understood and assessed as their performance of self-chosen occupations important in their

everyday lives [2]. Thus, reductions in service utilisation were not an inherent aim of ICC-

OT. Nevertheless, many of the activities that the older adults chose to work on (and

improved) in Study I were self-care and household activities such as those that older adults

can receive home care for [36, 37]. In addition, the older adults chose to work on physically

demanding leisure activities, which have a potential to improve their general health condition

[24]. For these reasons, it would have been highly relevant to evaluate whether the ICC-OT

was cost-effective in the short or longer term.

To provide occupational therapists and administrators with a basis for decision making

concerning the use of home-based, client-centred, and occupation-based OT in Danish

municipal elder care, the applicability of the results of the PhD study needs to be evaluated

[110]. Study I was carried out in the usual home-care context of a typical Danish municipality

and had many pragmatic features that support the applicability of ICC-OT in usual municipal

practice. However, some explanatory features were present concerning the organisation of

ICC-OT, and they should be taken into consideration. To be able to deliver home-based,

client-centred, and occupation-based OT to older adults, occupational therapists need

5. DISCUSSION

69

knowledge about the underlying theoretical concepts, about instruments for assessment and

goal setting, and about therapeutic strategies. They also need to be able to translate this

knowledge into their own therapeutic practices. Some occupational therapists may need a

brush-up on theories about client-centred and occupation-based practice to be able to practice

according to these theories. Continuing education is frequently offered, e.g., by Danish

university colleges and can be tailored to fit education needs in the Danish municipalities [e.g.

147]. In Study I, the ICC-OT included an average of 15 OT visits. This was a high intensity

compared to the usual practice, and should the ICC-OT or similar intensive OT interventions

be delivered to a larger number of older adults than today, sufficient additional occupational

therapist resources would need to be allocated. In summary, home-based, client-centred, and

occupation-based OT seems readily applicable to Danish municipal practice, giving due

consideration to a possible need for a theoretical brush-up among occupational therapists, and

to allocation of sufficient therapist resources.

5.2. Therapeutic approaches and strategies to deal with performance

problems

General client-centred and occupation-based therapeutic approaches were used Studies I, II,

and III, partly as a consequence of the focus of the PhD study. However, goal setting,

negotiating a therapy plan, and tailoring the intervention to the individual are also intrinsic in

occupational therapy practice models used in general OT practice [19,21]. To practise

activities, which was also a general therapeutic strategy in Studies I, II, and III is not always

included in OT, although OT interventions are generally focused on occupational

performance. In addition to being a general therapeutic approach, older adults from Study III

seemed to have adopted ‘practising activities’ as a personal strategy post OT to further

improve their performance. This may be because they had found that practising activities had

helped them improve their performance during OT. In addition to practising, the older adults

in Study III also stressed the importance of continuing to perform activities, staying active

and doing all they could themselves. As long as older adults have a potential to improve their

occupational performance, ‘practising activities’ seems to be a reasonable strategy, yet in the

case of persistent problems, it may lead to disappointment and feelings of sadness or failure,

as expressed by some older adults in Study III and in other studies [4,41,42].

5. DISCUSSION

70

Looking into the specific change strategies in the developed strategy chart (Table 9) shows

that when improvement and maintenance of occupational performance is the aim, the

strategies are about doing something actively to change or solve a problem. This is in

accordance with Folkman and Lazarus’ description of problem-focused coping strategies

[148] and with their finding that problem-focused strategies are often used in stressful

situations perceived as modifiable [149]. Some of the strategies in the strategy chart to

improve and maintain occupational performance have also been applied by older adults who

have not undergone rehabilitation [e.g. 10,12,75,150]. However, older adults who face

performance problems due to health issues are referred to OT when they are not able to come

up with effective performance strategies without professional help [14,15].

The strategy of adapting physical surroundings to the needs of participants in the OT was

widely used in Study I, II, and III. In Study I, a statistically significantly higher number of

assistive devices were allocated to the ICC-OT group than to the Usual-Practice group during

the first 3 months. This suggests that the strategy of using assistive devices may have played

an important role in the achieved effect of the ICC-OT [2]. Assistive devices and home

modifications have also, in previous studies, proved to be of importance for achieving and

maintaining independence in daily occupations [e.g. 62,151-153]. All participants were

entitled to assistive devices as part of usual practice. However, the larger number of assistive

devices provided for use in the ICC-OT group suggests that when older adults are met by

occupational therapists with professional knowledge about how assistive devices can support

occupational performance, this strategy is more widely used. Opposing views on assistive

devices prevailed among the older adults in Study III, and the wish to get rid of one’s assistive

devices resemble findings from previous studies [e.g. 154,155]. Lund and Nygård have

explained how the unwanted consequences of using assistive devices, including an undesired

self-image, may result in withdrawal from valued occupations [154]. It is therefore important

that occupational therapists acknowledge and address older adults’ possible reluctance

towards assistive devices and their desired self-image when suggesting assistive devices as a

strategy to improve and maintain occupational performance. Use or non-use should be

discussed in the context of the older adult’s general wish to be independent in everyday life.

The strategies used to deal with performance problems reported in Study III should be seen in

the light of the timing of the performed interviews. The older adults, whose participation in

home-based OT was not more than 3 months away, expressed great interest and motivation to

5. DISCUSSION

71

continue practising activities and working on improving personal capacities with a hope to

further improve their occupational performance. Such striving and motivation should be

acknowledged and supported, and existing offers for older adults at municipal rehabilitation

centres may supplement the older adults’ own initiatives. However, some of these older adults

in Study III who were so motivated for improvement at the time of the interviews would,

eventually, come to a point where they would need to change their strategies. (In fact, this had

already happened to some participants in Study III). A need to change strategies, as well as a

need for reinforcement to be able to maintain one’s occupational performance could be

addressed through follow-up contacts with an occupational therapist after the end of home-

based OT, and former studies have shown that reinforcement initiatives applied after

rehabilitation can improve treatment compliance and self-efficacy [156,157]. In one article

included in Study II, phone calls and a follow-up visit were used to reinforce and generalise

the use of strategies post intervention [122]. However, in spite of this initiative, the

improvements achieved in the short term were not maintained in the long term [122]. This

result, seen in the light of the reported general tendency of diminishing effects post home-

based OT in Studies I and II [2,3], speaks for further development of reinforcement

initiatives. The strategy chart (Table 9) contains suggestions that can be used during such

initiatives. In some cases, a one-to-one session (or more) in the home between the older adult

and an occupational therapist may be needed. In other cases, community-based solutions may

be a good choice; the reinforcement strategy of having binding appointments with others, for

instance, as mentioned in Study III, to take walks with a friend or to attend a group exercise-

programme, may be suggested.

Strategies to deal with persistent performance problems (present or expected future problems)

derived from Study III are also presented in the strategy chart (Table 9). Folkman and Lazarus

have found that in situations perceived as unchangeable, people use emotion-focused

strategies to a higher degree than problem-focused strategies [149,158], and the strategies in

the strategy chart that imply changes within the person to deal with persistent performance

problems may be interpreted as the emotion-focused coping strategies distancing and positive

reappraisal [148]. However, some of the coping strategies described by Folkman and Lazarus

may have gone undetected in Study III, because the aim of the study was not to detect specific

coping strategies. The coping strategies distancing and positive reappraisal, used to deal with

persistent limitations, were also found in a Canadian study among older adults with health

5. DISCUSSION

72

issues who had not had OT [75]. As seen in the strategy chart, not only emotion-focused but

also some problem-focused strategies are included to deal with persistent performance

problems, pertaining to changes within the environment and within the occupation. Some of

these may be suggested by occupational therapists as an alternative or supplement to emotion-

focused strategies in an attempt to achieve satisfying occupational engagement. Occupational

engagement has been defined as encompassing ‘all that we do to involve ourselves or become

occupied’ and it includes ‘occupational performance as well as subjective experiences

associated with occupational performance: aspects of meaning, interest, motivation, and/or

perceived self-efficacy’ [129]. The feelings of sadness and failure expressed by older adults in

relation to unresolved performance problems [e.g. 4,42], may indicate that they had used

inefficient emotion-focused or problem-focused strategies to deal with persistent problems. It

may also be a sign of decreased feelings of engagement. This calls for reflection among

occupational therapists about how we conclude our home-based interventions with older

adults. It may seem natural to end the therapy with advice to stay active, to motivate for

further ‘practising’, etc., and in many cases the older adults need and like such encouragement

[4]. However, the losses, the persistent problems, and the need to deal with those also in the

future ought to be addressed, too.

Goal setting was used in all the OT interventions reported in the PhD study (Table 9). This

strategy can help to focus on the most important aspirations of a client and help the client to

stay motivated during a period of rehabilitation or therapy [159]. When offering OT

interventions with the aim to improve occupational performance (as was the focus of the

RCTs in Studies I and II), goals are naturally formulated in terms of ‘independence in’, or at

least, ‘better performance of’ various activities. Sometimes, the goals are set high to motivate

the older adult [160]. Nevertheless, when delivering OT services to older adults with very

limited occupational performance, goals should obviously not always be about becoming

independent or better performers. Less lofty goals can be perfectly legitimate! Besides

improving occupational performance, our profession also aspires to enable occupational

engagement, which does not imply that the person is independently, or at all actively, ‘hands-

on’ involved in an occupation, as long as she or he is involved in some way in the occupation

[129,130].

Performing activities with others, a strategy much praised by older adults in Study III, is a

way of engaging in occupations that has also been reported as treasured by older adults in

5. DISCUSSION

73

other studies [11,76,154]. This strategy may therefore be suggested by the occupational

therapist as a way to engage in occupations in situations involving declining abilities.

Performing with others can be adapted to the older adult’s level of participation, it may be

done with a spouse/relative or a hired help, as in Study III, with a voluntary visitor, or be

integrated in home care.

In summary, the chart of therapeutic approaches and specific strategies found useful during

and after home-based OT (Table 9) may inspire occupational therapists who work with

enabling occupational performance and engagement in older adults, as it provides ideas

regarding how to work therapeutically by improving and maintaining occupational

performance and by dealing with persistent performance problems. Combinations of

strategies should be tailored to the individual older adult’s situation and preferences, and

attention should be payed to situations where older adults need help to change their strategies.

The general therapeutic approaches collaborative goal setting, negotiation of therapy plan,

tailoring strategies to the individual, and practising activities are recommended for home-

based OT, as well as the strategy appliance of assistive devices and home modifications,

because they were intrinsic parts of the interventions that were found effective in Studies I

and II. Additional strategies to improve and maintain occupational performance and to deal

with persistent performance problems serve as suggestions.

5.3. The mixed methods design of the PhD study

The sequential mixed methods design addressed the overall aims of the PhD study and

provided a two-phase structure which was straight forward to implement [77]. The design

enabled connecting between the studies; nevertheless, the choice of timing of the three studies

in the sequential mixed methods design (see Figure 2 in Chapter 3) had advantages as well as

disadvantages. The RCT and the literature review were both performed in Stage 1, and thus

the result of one study could not influence the design of the other. This was a consequence of

the initiation of the RCT before my PhD study. Fortunately, the results of the literature review

could be used in the discussion of the results of the RCT. It would have been an advantage,

however, if the literature review had been performed and analysed before the RCT, as

recommended within intervention development [72]. Specifically, the results from the

literature review about problems with long-term effectiveness could have led me to advocate

for a longer follow-up in the RCT study. It could then have been explored whether the greater

5. DISCUSSION

74

intensity of the ICC-OT would lead to better long-term effectiveness than the less intensive

interventions reported in the literature review. The mixed results from the review about long-

term effectiveness could also have led to changes in the therapeutic strategies used in the

ICC-OT intervention. Specific emphasis could have been put on how to improve

generalisation and transfer in an attempt to improve long-term effectiveness.

Although a qualitative study was planned to take place after the first stage to achieve a better

understanding of older adults’ everyday life experiences post home-based OT, the precise

study questions were developed and refined during the intermediate analysis. This was an

advantage, since the challenge of generalisation and transfer of strategies from OT to

everyday life post OT was not evident to me from the beginning of the PhD study. Similarly, I

was not aware of the knowledge gap concerning older adults’ occupational performance after

home-based OT, including their own strategies to deal with their performance problems. The

knowledge created in the PhD study about which strategies the older adults had adopted in

their daily lives post OT may have gone unnoticed had I not been tuned in on their

occupational performance post OT through the intermediate analysis.

In summary, the sequential mixed methods design of the PhD study added an extra dimension

to the study. A fuller picture of the outcomes from home-based OT was provided, and well-

founded suggestions of strategies to improve the intervention could be developed by merging

the findings from the two stages of the PhD study.

5.4. Strengths and limitations of Studies I, II, and III

Strengths and limitations of importance to the reliability and internal validity

The efforts to ensure validity and reliability in each study are described in the methods

chapter. In summary, reliability and internal validity were ensured through the choice of

strong designs, methodologies, and instruments, through rigorous use of methods, through the

skilled occupational therapists who performed the interventions and assessments, through the

experts and peer researchers included in the processes of producing and analysing data, and

by the inclusion of samples of relevance to the research questions.

Some limitations should be mentioned that are of importance for the reliability and internal

validity of the studies. In Study I, the take-up rate of 18% was low. The major reason for not

participating was health issues, which indicates that participating in an intensive OT

5. DISCUSSION

75

intervention or in an RCT, or both, did not attract all older adults. The loss to follow-up was

high: 18% at 3 months and 22% at 6 months on the main outcome, and reasons for declining

reassessment were often linked to health issues. However, an analysis that used single value

imputations and took general health at baseline into consideration did not change the main

conclusion. The older adults could not be blinded to the intervention, and negative or positive

experiences may have influenced their answers at follow-up when the self-reported

instruments were used [117]. In Study II, despite the thorough literature search, some articles

may have gone unnoticed. Furthermore, some articles were excluded because the

interventions included a major input from professionals other than occupational therapists.

Thus, some results – positive or negative – of home-based interventions including OT were

not included in the review. The conclusions built on a limited number of articles. Meta-

analyses were not deemed feasible; thus no pooled estimates were produced. The summaries

of findings were the best ‘second choice’ [125], and they made it possible to produce an

overview of the best current evidence. In Study III, the older adults may have been influenced

by knowing that they were interviewed by an occupational therapist. They may for example

have put extra emphasis on ‘practicing’ when accounting for their strategies to improve and

maintain occupational performance, despite my aspiration to elicit and understand their

individual experiences, feelings, and strategies. The inductive qualitative content analysis

does not allow the researcher to describe the full meaning of data, because the researcher does

not go back and forth between interpretations and data while taking more and more aspects

into account [80 p.3]. Nevertheless, the analysis allowed me to systematically describe what

the older adults had said and to get an overview of the parts of the material that were clearly

relevant to the research questions.

Strengths and limitations of importance to the external validity and analytical

generalisation

Older adults with a breadth of multiple chronic health issues were represented in all three

studies. The health issues were mainly physical, although some cognitive problems were also

present among participants who had had a stroke. Therefore, the external validity and

analytical generalisation [83] pertain to older adults with multiple, chronic, and mainly

physical health issues referred to OT in Danish municipalities due to performance problems.

Only a few older adults with mental health issues participated in the studies. In Study I, only

5. DISCUSSION

76

nine of the 215 reported problems were mental health issues, in Study II, mental health issues

were not accounted for in any of the articles, and in Study III, no participants reported a

mental health issue. A depression, which is more common among older adults than in the

population as a whole [161], could for instance have influenced the choice of whether to

participate in home-based OT as well as which therapeutic and personal strategies would be

chosen to deal with performance problems. The results and experienced outcomes among

older adults with depression could well differ from those of the study participants in Studies I,

II, and III.

None of the older adults in Studies I and III were born and raised outside Denmark or lived

with their families. Among older adults who fall into one or two of these categories, culturally

based perceptions of occupational performance and the family role of an older adult may

influence which performance problems are deemed important, the amount of help offered by

the family, and subsequently the therapeutic and personal strategies applied to deal with


A further caveat should be mentioned. Participants in scientific studies cannot be expected to

fully represent the population of interest because they are specially invited and have

volunteered to participate [162]. The older adults included in the studies may have been more

motivated for participating in home-based OT and for sharing their experiences than other

older adults might have been. In Study III, the older adults were selected by the managers of

the OT. This may have influenced the composition of the sample, because the participants

were articulate and all had experienced some positive outcomes from OT. Thus, they did not

represent all older adults who receive OT in their homes, especially not those who may not

have profited greatly from the intervention. Nevertheless, nine of the 11 older adults reported

some unresolved performance problems, and two had daily help with self-care activities due

to permanently low functional levels; these perspectives added to the diversity of the findings.

Only two men were represented in the sample in Study III. The two men differed concerning

their health and social situations, which added to variation concerning the problems they had

worked on during OT, their outcomes, and the degree of support they had in the home.

However, including more men could have led to further insights.

The empirical studies took place in the Danish welfare state, where the social security for

older adults is high, and largely tax financed home-based services such as OT, assistive

5. DISCUSSION

77

devices, minor home modifications, practical help, and personal assistance, are provided to all

citizens when certain criteria are met. In consequence, both study groups in Study I were, in

principle, entitled to the above-mentioned services save intensive OT. This must be taken into

consideration when comparing the results with those of studies from other countries, where

citizens may not have access to these services or may have to pay for some or all of them.

In summary, the results and findings build on sound and robust research, yet they cannot be

generalised to all older adults. The findings pertain to home-dwelling older adults with

performance problems due to multiple chronic and mainly physical health issues.

Furthermore, the findings pertain to older adults who live alone or with a spouse in a

Scandinavian welfare state, where they have been born and raised, and who find it

manageable to participate in home-based OT. The findings from the qualitative study may be

analytically generalised to other groups of older adults who receive home-based, client-

centred, and occupation-based OT, and the developed strategy chart may provide suggestions

for occupational therapists to include in their future practice among home-dwelling older

adults with performance problems.

6. CONCLUSIONS

78

6. CONCLUSIONS

Novel insight into home-based OT for older adults was achieved through the present PhD

study. The overall aims of the PhD study were to examine whether home-based, client-

centred, and occupation-based OT may help older adults to improve and maintain their

occupational performance, and to understand how older adults experience and deal with their

occupational performance post OT. A main result of the PhD study is that the ICC-OT, which

encompasses all three abovementioned features, can effectively improve the occupational

performance of older adults in the short term. Another main result is a strategy chart with

general therapeutic approaches and suggestions regarding specific change strategies with two

different aims: to improve and maintain occupational performance and to deal with persistent


Hence, home-based, client-centred, and occupation-based OT can be an effective intervention

to improve self-reported and therapist-observed occupational performance of older adults with

multiple chronic and mainly physical health issues who have the energy and motivation to

participate in the intervention. The type of intervention seems well received by older adults,

the positive results are valued, and the intervention seems applicable to Danish municipal

practice.

The general therapeutic approaches collaborative goal setting, negotiation of therapy plan,

tailoring strategies to the individual, and practising activities, in the strategy chart are

recommended for home-based OT, as well as the strategy appliance of assistive devices and

home modifications. Additional strategies to improve and maintain occupational performance

and to deal with persistent performance problems serve as suggestions..

7. IMPLICATIONS FOR PRACTICE AND RESEARCH

79


The ICC-OT seems readily applicable to Danish municipal practice – if due consideration is

given to the possible need for a theoretical brush-up among occupational therapists and to

allocation of sufficient therapist resources.

Further emphasis should be put on ensuring generalisation and transfer of the therapeutic

strategies from OT to occupational performance post OT, and on supplementing and

strengthening the older adults’ personal strategies to maintain their occupational performance.

A programme of lower intensity may be considered to enable older adults with fewer

participation resources. The findings suggest that older adults with persistent performance

problems may need OT interventions that focus on maintaining their occupational

performance and on dealing with irreversible decline. Satisfactory engagement in occupations

could in such situations be prioritised over independent performance. This calls for other

strategies than those adopted when aiming for improved occupational performance.

Intervention development and research is recommended to further improve the effectiveness

of home-based, client-centred, and occupation-based OT in the short and in the longer term.

Focus could for instance be on teaching problem-solving strategies, and on how older adults

can generalise such strategies to their daily occupations post OT and transfer them to deal

with performance problems that emerge post OT. To improve our knowledge about the long-

term effectiveness of home-based, client-centred, and occupation-based OT, and about the

economic aspects, it is recommended that future research includes a follow-up, for instance 6

months post OT, and that health economic evaluations should be embedded. Research is also

needed concerning which additional groups of older adults may benefit from ICC-OT and

similar interventions. The interventions could profitably be tested among older adults with

mental health problems as well as older adults returning home after a hospitalisation. The

ICC-OT tested in the PhD was, although delivered in a usual practice context, largely mono-

disciplinary. Future research may show how periods of ICC-OT embedded within home-care

reablement may accommodate older adults who have the motivation and energy to participate

in a more intensive intervention with a wider choice of goals.


80

Finally, it would be fruitful, through participatory research, to include older adults and

practicing occupational therapists in validation and further refinement of the chart of

strategies to deal with performance problems that was developed for the dissertation..

8. REFERENCES

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9. TABLES AND FIGURES

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9. TABLES AND FIGURES

Tables

Table 1. In- and exclusion criteria for Study I

Table 2. In- and exclusion criteria for Study II

Table 3. In- and exclusion criteria for Study III

Table 4. Demographics and baseline assessments. Older adults reassessed and not

reassessed at 3 months. Study I

Table 5. Occupational performance: within-group changes and between-group differences in

change. Study I

Table 6. The effect of OT on occupational performance of older adults with multiple chronic

health issues. Study II

Table 7. Demographic and self-reported clinical data of the participants in Study III

Table 8. Research questions, categories, and codes. Coding frame developed in Study III

Table 9. Strategy chart. Approaches and strategies to deal with older adults’ performance problems

Figures

Figure 1. The Person-Environment-Occupation (PEO) Model

Figure 2. The mixed-methods design of the PhD study

Figure 3. Participant flow. Study I

Figure 4. Characteristics of the ICC-OT intervention. Study I

Figure 5. PRISMA flow diagram. Study 2

Figure 6. COPM performance scores at baseline, 3, and 6 months. Study I

Figure 7. The influence of health status on change in COPM from baseline to 3 months. Study I

10. APPENDICES

93

10. APPENDICES

Appendix 1, Article 1

Nielsen TL, Andersen NT, Petersen KS, Polatajko H, Nielsen CV. Intensive client-centred

occupational therapy in the home improves older adults’ occupational performance. Results

from a Danish randomized controlled trial.

Published in: Scandinavian Journal of Occupational Therapy. DOI number

10.1080/11038128.2018.1424236. Published online: 12 Jan 2018.


Nielsen TL, Petersen KS, Nielsen CV, Strøm J, Ehlers MM, Bjerrum M. What are the short-

term and long-term effects of occupation-focused and occupation-based occupational therapy

in the home on older adults’ occupational performance? A systematic review.

Published in: Scandinavian Journal of Occupational Therapy 2017;24:235-48.


Nielsen TL, Bjerrum M, Nielsen CV, Petersen KS. Older adults’ experiences and expectations

after discharge from home-based occupational therapy.

Accepted for publication by British Journal of Occupational Therapy January 2018. DOI

number 10.1177/0308022618756217. In press.

Appendix 4

Intermediate Analysis between Stage 1 and Stage 2

Appendix 1

Article 1

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Intensive client-centred occupational therapy inthe home improves older adults’ occupationalperformance. Results from a Danish randomizedcontrolled trial

Tove Lise Nielsen, Niels Trolle Andersen, Kirsten Schultz Petersen, HelenePolatajko & Claus Vinther Nielsen

To cite this article: Tove Lise Nielsen, Niels Trolle Andersen, Kirsten Schultz Petersen, HelenePolatajko & Claus Vinther Nielsen (2018): Intensive client-centred occupational therapy in the homeimproves older adults’ occupational performance. Results from a Danish randomized controlledtrial, Scandinavian Journal of Occupational Therapy

To link to this article: https://doi.org/10.1080/11038128.2018.1424236

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ORIGINAL ARTICLE

Intensive client-centred occupational therapy in the home improves olderadults’ occupational performance. Results from a Danish randomizedcontrolled trial

Tove Lise Nielsena,b,c , Niels Trolle Andersend, Kirsten Schultz Petersene, Helene Polatajkof andClaus Vinther Nielsena,c

aSection for Clinical Social Medicine and Rehabilitation, Department of Public Health, Aarhus University, Aarhus, Denmark;bDepartment of Occupational Therapy, VIA University College, Aarhus, Denmark; cDEFACTUM Central Denmark Region, Aarhus,Denmark; dSection for Biostatistics, Department of Public Health, Aarhus University, Aarhus, Denmark; eDepartment of Health Scienceand Technology, The Faculty of Medicine, Public Health and Epidemiology Group, Aalborg University, Aalborg, Denmark; fDepartmentof Occupational Science and Occupational Therapy, and Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada

ABSTRACTBackground: There is growing interest in enabling older adults’ occupational performance. Wetested whether 11 weeks of intensive client-centred occupational therapy (ICC-OT) was superiorto usual practice in improving the occupational performance of home-dwelling older adults.Methods: An assessor-masked randomized controlled trial among adults 60þwith chronichealth issues, who received or applied for homecare services. Recruitment took place September2012 to April 2014. All participants received practical and personal assistance and meal deliveryas needed. In addition, they were randomized to receive either a maximum 22 sessions of occu-pation-based ICC-OT (N¼ 59) or to receive usual practice with a maximum three sessions ofoccupational therapy (N¼ 60). The primary outcome was self-rated occupational performanceassessed with the Canadian Occupational Performance Measure (COPM).Results: No important adverse events occurred. ICC-OT was accepted by 46 participants (88%),usual practice by 60 (100%). After 3 months, the ICC-OT-group had improved 1.86 points onCOPM performance; the Usual-Practice group had improved 0.61 points. The between-group dif-ference was statistically significant (95% confidence interval 0.50 to 2.02), t-test: p¼ 0.001.Conclusions: ICC-OT improved older adults’ occupational performance more effectively thanusual practice. This result may benefit older adults and support programmatic changes.

ARTICLE HISTORYReceived 9 June 2017Revised 20 December 2017Accepted 2 January 2018

KEYWORDSClient-centred; home;occupation-based; occupa-tional therapy; occupationalperformance; older adults

Introduction

In Denmark, as in many other countries, promotingolder adults’ ageing in place is a major aim supportedby policy makers and service providers, who anticipatedramatic increases in welfare costs due to ongoingdemographic changes [1–3]. In addition, there is grow-ing interest in transferring some of the traditional pas-sive services for older adults to rehabilitation, in anattempt to maintain older adults’ functional ability andto enable their occupational performance and wellbeing[1–3]. In Denmark, most older adults live alone or witha spouse; 33% of 65–79 year-olds and 66% of 80þ year-olds live alone [4]. Danish elder care, includingrehabilitation, is a universal service; the responsibilitylies at the local level in the municipalities, and all olderadults have access free of charge, when certain criteria

are met [3]. A Danish national report sums up possibil-ities and challenges regarding older adults’ participationin rehabilitation [5]. The report is informed by a num-ber of evaluations based on interviews with older adults.To be able to reestablish one’s previous level of func-tioning was a general aim and motivational factoramong the participants of the evaluations. The samepertained to a wish to live independently, especiallymanaging one’s personal care alone. The wish to beindependent with regard to housekeeping was lessstrong. Indeed, older adults who felt lonely were gener-ally less interested in becoming independent, as theyfeared they would be deprived of their homecare assis-tants [5].

Occupational therapy (OT) is a valued and well-integrated profession within rehabilitation for older

CONTACT Tove Lise Nielsen [email protected]� 2018 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis GroupThis is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, trans-formed, or built upon in any way.

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adults [6–9]. In the rehabilitation context of Danishmunicipalities, home-based OT is typically deliveredto older adults in one of two ways: (1) As a compre-hensive client-centred OT intervention building onthe older adults’ own goals and planned and deliveredby occupational therapists through the full period ofrehabilitation, in some cases as part of a multidiscip-linary approach [10,11], or (2) As an element ofhomecare re-ablement where occupational therapistswork as consultants to the homecare personnel [10].

The core of OT is to enable clients’ occupationalperformance and wellbeing [12,13]. Occupational per-formance may be improved through occupation-basedOT where occupation acts as both means and end.Typically, acquisitional, adaptive and restorative inter-vention models are used, and the occupations, whichthe older adults want or need to do, are addressed ina client-centred process [13–16]. Client-centred prac-tice within OT is defined by the Canadian Associationof Occupational Therapists as collaborativeapproaches aimed at enabling occupation with clients[17]. It is stressed that in client-centred practice:

Occupational therapists demonstrate respect for clients,involve clients in decision-making, advocate with andfor clients in meeting clients’ needs, and otherwiserecognize clients’ experience and knowledge [17].

Client-centred OT is generally valued and practisedwithin Danish OT, and the Canadian OccupationalPerformance Measure (COPM), which supports thispractice, is widely used in Danish municipalities [18].Client-centredness holds a high priority in Danish OTcurricula, informed by Canadian and US conceptualand practice models and outcome measures[13,14,17,19,20]. Gupta and Taff [21] have argued thatclient-centred practice is best embodied by occupa-tion-focused interventions in the natural environmentof everyday living. This supports the provision of OTin and around the client’s home. Challenges in client-centred practice have been identified at the level ofthe healthcare system [22]. In Denmark, homecare re-ablement for older adults is becoming increasinglywide spread [23]. A client-centred approach to home-care re-ablement is supported by law through the con-solidating act on social services, which emphasizescooperation with the client and building on the client’sindividual goals [10]. Nevertheless, at the time the pre-sent study was carried out, Danish occupationaltherapists’ client-centred values and practices werechallenged. Local policies in many Danish municipal-ities downplayed individual goal-setting by limiting thefocus of homecare re-ablement to the performance oftasks and activities for which the older adults would

otherwise be eligible to receive help. The aim was tosave municipal homecare costs. In addition, theamount of OT within homecare re-ablement was insome municipalities limited to a few visits or no OT atall, and the re-ablement was mainly carried out byhomecare assistants. This situation is what we refer toas ‘usual practice’ (as opposed to client-centred) in thepresent study.

Occupational therapists are obliged to work in anevidence-based manner [24]. Yet there is a paucity ofquality intervention literature, and client-centred andhome-based OT for older adults has not previouslybeen tested in a Danish context. A recent systematicliterature review identified only a small number ofhigh-quality studies concerning home-based and occu-pation-based OT [25]. The studies were predominantlyEuropean and North American, and the interventionswere with older adults post stroke, with Parkinson’sdisease, or with various chronic health issues [25].While OT was found to effectively improve occupa-tional performance within the domains of self-care,productivity, and client-identified occupations [26–31],small effect sizes were reported in several studies[26,27,31], and there were problems with maintainingthe achieved improvements after discharge [27,29].The amount of OT in the studies ranged from two tonine sessions [25]. However, the authors did not exam-ine the relationship between amount and outcome.Previous studies have shown that a larger amount ofOT and physiotherapy could improve clients’ outcomesin inpatient settings, and that the amount of OT wasfrequently far too small to be effective [32–34]. Thereis therefore a need to test the effect of in-home inter-ventions that are more intensive than those reported inthe above-mentioned literature review. Furthermore,many older adults who receive home-based services areaffected by a range of chronic and often concurrenthealth issues and have very different needs.Accordingly, it is important to examine the effective-ness, over time, of intensive, client-centred occupation-and home-based OT targeting diverse populations.

Objectives and hypotheses

The objective of this study was to compare 11 weeksof occupation-based intensive client-centred OT (ICC-OT) in the homes of older adults to the usual practicein one Danish municipality. One primary hypothesiswas formulated:

Primary hypothesis: ICC-OT will be superior tousual practice in improving the participants’ self-rated

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occupational performance, measured as the changebetween the assessments at baseline and 3 monthspost baseline.

Secondary hypotheses were formulated, building onour expectations that the ICC-OT would outperformusual practice on three counts: participants’ would bemore satisfied with the occupational performance(Secondary hypothesis 1); the observed quality of occu-pational performance would be higher (motor abilitiesand process abilities, Secondary hypothesis 2 and 3);and health-related quality of life would be increased(physical components and mental components,Secondary hypothesis 4 and 5), measured as thechanges in these variables between the assessments atbaseline and 3 months post baseline.

Finally, we expected that the improvements oneach of the six above-mentioned outcomes would bemaintained 6 months later, i.e. compared with base-line, the ICC-OT group would fare better than theUsual-Practice group (Secondary hypothesis 6 to 11).(Table 3 refers to the numbered hypotheses).

Methods

A randomized controlled parallel group superioritytrial was performed with an allocation ratio of 1:1 toICC-OT or usual practice, and assessor-maskedassessments at baseline, and at 3 and at 6 months,post-baseline.

Setting and standard services

The study took place in The Municipality of Randers(Randers Kommune), a Danish municipality of 97,500inhabitants, of which 25% were 60þ years old [35].Personal care, practical help, meal delivery, OT,homecare re-ablement, physiotherapy, assistive devicesand minor home modifications were the responsibilityof a municipal homecare office. The services were

offered free of charge to home-dwelling older adultswith functional limitations when specified require-ments were met [10]. Participants in both studygroups were eligible for these standard services. Theonly differences in services pertained to OT andhomecare re-ablement.

Table 1 presents details concerning the rehabilita-tive services received in the trial period. Within thefirst 3 months, more participants in the ICC-OTgroup than in the Usual-Practice group receivedassistive devices and minor home modifications (24vs. nine), chi-square test: p¼ 0.002.

Participants

Included in the study were older men and womenaged 60þ. They experienced occupational perform-ance problems and were therefore applying for, oralready receiving, homecare services. They lived inprivate homes or in sheltered housing and were ableto communicate in Danish. Excluded were olderadults with physician-ascertained alcohol or drugabuse, tetraplegia, dementia, severe mental illness orsevere intellectual disability. Also excluded were olderadults who had severe pain and/or rapidly progressivediseases such as cancer or motor neuron disease.These criteria assured that participants in the studywere similar to those who would usually be consid-ered for rehabilitation. Further exclusion criteria were:having a rehabilitation plan from a hospital, previousparticipation in homecare re-ablement, or living witha participant of the present study.

Enrolment and randomization

A homecare officer at a central municipal officeinvited older adults to participate in the study whenthe older adults applied for homecare for the firsttime or were about to have their needs reevaluated.

Table 1. Details concerning the received rehabilitative services in the trial period.ICC-OT group

n¼ 59 at baseline, n¼ 46 at 3 monthsUsual-Practice group

n¼ 60 at baseline, n¼ 53 at 3 months

ICC-OT from baseline to 3 months 52 participants had, on average, a total of11 hours over 15 sessions

OT delivered as part of usual practice frombaseline to 3 months

14 participants had, on average, a total of3.1 hours

Physiotherapy from baseline to 3 months 9 participants had, on average, a total of5.4 hours

5 participants had, on average, a total of6.6 hours

ADsa from baseline to 3 months 24 participants had 39 ADs in all 9 participants had 15 ADs in allOT delivered as part of usual practice from 3

months to 6 months3 participants had, on average, a total of

0.8 hours3 participants had, on average, a total of

3.6 hoursPhysiotherapy from 3 months to 6 months 12 participants had, on average, a total of

5.4 hours6 participants had, on average, a total of

7 hoursADsa from 3 months to 6 months 8 participants had 16 ADs in all 10 participants had 15 ADs in allaAssistive devices and minor home modifications. ICC-OT: Intensive Client-Centred Occupational Therapy.

SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 3

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Initial information was given by means of a standar-dized telephone-protocol. Research occupationaltherapists visited the older adults, checked eligibilitycriteria and gave oral and written information.Willing participants gave written informed consentand went through the baseline assessments. Finally, ahomecare officer assigned the participants to the ICC-OT or usual practice arm of the study. The officer fol-lowed a computerized randomization procedure gen-erated by a data management team. Blockrandomization produced balanced study arms. Theblock sizes and the random allocation sequence wereconcealed until all participants were assigned to theirgroups. Recruitment took place from 1 September2012 to 30 April 2014. The last follow-up was per-formed 31 October 2014.

Intensive client-centred occupational therapy (ICC-OT)

Figure 1 depicts the characteristics of the ICC-OTintervention performed by the research occupationaltherapist. The ICC-OT took place in and around theparticipants’ homes and in other environments of thelocal community, as appropriate given the partic-ipants’ performance issues and goals. One researchoccupational therapist was assigned to each partici-pant. Key points in the ICC-OT that reflected theclient-centred approach [13,19] included respectingthe older adults’ individual life styles; seeking, respect-ing and addressing their priorities and choices con-cerning the focus of the OT intervention; workingcollaboratively on goal-setting and during the inter-vention; and assessing the older adult’s performancewith an individualized client-centred outcomes meas-ure before and after the intervention. It was possibleto change the original goals and to work on new/add-itional goals if such should evolve during the process.

The protocol (see Figure 1) specified up to 11weeks of ICC-OT (Week 2 to 12) with two sessionsper week and a maximum of 22 sessions. The aim ofthe ICC-OT was to improve occupational perform-ance. Occupations, named and prioritized on theCOPM [20] by the participants at the baseline assess-ment, were targeted. Goal-setting took place Week 3;the goals addressed improving occupational perform-ance within the self-care, productivity and leisuredomains. The therapeutic phase (Week 3 to 12) to alarge degree involved practising the necessary tasksand activities to achieve the goals. The ICC-OT wastailored to the individual and built on acquisitional,adaptive and restorative models [14]. During the 11weeks of ICC-OT, no other OT was available to the

participants in this group. In Week 13, the partici-pants went through the 3-month assessment. Theythen received usual practice for the last 3 months oftheir participation in the study, until the 6-monthassessment.

Table 1 presents details concerning received ICC-OT in the trial period. At group level, the occupationsworked on during the ICC-OT were fairly evenly dis-tributed on self-care (32%), productivity (39%) andleisure (29%). The most frequent occupations workedon were, for self-care: dressing, bathing, grocery shop-ping and functional mobility; for productivity: clean-ing, cooking and laundry; and for leisure: hobbies,walks and visiting friends. The occupation-basedapproach was reflected by the choice of interventionmodels. Aquisitional models were used 55% of thetime, adaptive models 41% of the time and restorativemodels 4% of the time. One adverse event wasreported: a participant cut himself with a knife duringa kitchen activity.

Usual practice

Participants in the Usual-Practice group received noinput from the research occupational therapists. FromWeek 2, it was possible (though not mandatory)for the participants to be referred to homecare re-ablement. This was a part of the usual practice of themunicipality and was initiated when the homecareofficers considered that the participants had potentialfor improvement in tasks or activities for which theywould otherwise require help. Homecare re-ablementtook place in the home and lasted up to 3 weeks. Itcould include three visits by a municipal occupationaltherapist but was mainly performed by homecareassistants. The tasks and activities that could beworked on were restricted to the areas of self-careand household management. It was not a specific,client-centred approach, and the participants couldnot choose freely what to work on. The participantsperformed the tasks and activities, and the assistantsgave advice and help when needed, e.g. on how tosimplify a task or use an assistive device. The home-care re-ablement staff had no access to the results ofthe baseline assessments. Thirteen weeks (3 months)after baseline, the participants went through the 3-month assessment and continued receiving usualpractice for the last 3 months of their participation inthe study, until the 6-month assessment.

Table 1 presents details concerning received usualpractice in the trial period. No documentation wasavailable concerning the exact tasks and activities


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addressed when participants of the Usual-Practicegroup had OT.

Outcome measurements and their applicationin the study

Occupational performance and health-related qualityof life were measured at baseline, at the 3-monthassessment and at the 6-month assessment.

No changes to trial outcomes were made after thetrial commenced.

The primary outcome was self-rated occupationalperformance (Primary hypothesis); this was assessedby the Danish version of the Canadian OccupationalPerformance Measure (COPM) [20], which is a semi-structured, interview-based outcome measure designedto identify and prioritize occupational performanceissues and assess change [20]. The COPM was chosento match the client-centred focus of the ICC-OT

Figure 1. Characteristics of the ICC-OT intervention.


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intervention. It helps clients to formulate and evaluatetheir most important occupations and performanceissues and thus supports individual goal-setting andinterventions towards client-chosen goals [36]. TheCOPM has been validated in many populations,including a population of Danish older adults inhome settings [18,37]. The primary hypothesisaddressed the change from baseline to 3 months.Change from baseline to 6 months was addressed inSecondary hypothesis 6. The participants of the pre-sent study prioritized and chose up to five occupa-tional performance problems, and they scored theirability to perform each of these occupations using thenumerical, 10-point rating scale of the COPM. Asummary score (mean value of all five performanceratings) was computed, and this COPM performancescore, ranging from 1 to 10, was used for analysis. Atthe 3-month and the 6-month assessments, the partic-ipants rescored the same occupations without beingshown their earlier scores. If fewer problems wererescored than scored at baseline, the summary scorewas computed with the actual number of rescoredoccupations, as suggested in the COPM manual. Aminimal clinically important difference (MCID) of2 points for both COPM scores has been suggestedfor all populations [37], yet an MCID of 1.4 pointshas been suggested for the COPM performance scorebased on a study in a group of adults with varioushealth problems [38].

The secondary outcomes were self-rated perform-ance satisfaction, observer-rated performance quality,and health-related quality of life.

Self-rated performance satisfaction (Secondaryhypothesis 1 and 7) was assessed on the satisfactionscale of the COPM after the identification of problemsand scoring of performance. Again, the COPMnumerical scale from 1 to 10 was used [20]. TheCOPM satisfaction score, ranging from 1 to 10, wasscored and rescored in a similar fashion to the per-formance score, as explained above.

Performance quality (Secondary hypothesis 2, 3, 8,and 9) was assessed on the motor and process scalesof the observation-based and standardized Assessmentof Motor and Process Skills (AMPS) [39,40]. Thisassessment has been validated in many populations,including older adults, and in home settings[39,41–43]. The AMPS measures the degree to which aperson’s task performance is free of increased clumsi-ness or physical effort, decreased efficiency, safety risk,and/or need for assistance. The participants in the pre-sent study were observed during the performance oftwo chosen personal or domestic activities. The raw

item scores were converted into one linear ADL motorability measure (AMPS motor score, Secondaryhypothesis 2 and 8), and into one linear ADL processability measure (AMPS process score, Secondaryhypothesis 3 and 9) [44]. The many-facet Rasch modelof the AMPS allows for missing scores when calculat-ing the ability measures [44]. The scales range from �3to 4 logits [39,40]. An MCID of 0.3 points has beenrecommended [39] Assessors must be trained and cali-brated to use the AMPS test. To ensure validity in thepresent study, a post-hoc analysis of the AMPS assess-ments was performed at Center for Innovative OTSolutions [45]. Two hundred sixty-three assessments(97% of all the performed assessments) were deemedfree of rater scoring error and included in the statisticalanalyses. Nine assessments (3%) were excluded. Inaccordance with the AMPS manual, the assessors alsoreported up to three diagnoses per participant found tosubstantially affect his or her occupational performance[39,40].

Health-related quality of life (Secondary hypothesis4, 5, 10 and 11) was assessed using the Danish versionof the standardized 36-item short-form health survey(SF-36), Version 1.1 [46,47]. The SF-36 has been vali-dated in many populations, including a population ofolder Danish adults, and in home settings [46–50].The questionnaire was used in an interview setting[50]. The software computed eight subscales and twosummary measures. For the present study, theGeneral Health subscale (SF-36GH), the physicalcomponent summary (PCS, Secondary hypothesis 4and 10) and the mental component summary (MCS,Secondary hypothesis 5 and 11) were calculated andtransformed to scales ranging from 0 to 100. The soft-ware imputed missing values if conditions applied[51]. MCIDs of 3 to 5 points have been suggested inthe literature [52].

Participant information concerning received help,health issues, and sociodemographic data were col-lected using the central municipal administrativeregisters and by asking the participants themselves.A standardized form was created for this purpose.

Occupational therapists

In all, six registered occupational therapists wereinvolved in the assessments and the ICC-OT interven-tion: two full-time research occupational therapistsand four part-time assessors. All were educated inDenmark and had worked eight to 23 years withrehabilitation of Danish older adults. All were experi-enced users of the COPM and the AMPS. They


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participated in two 5-hour workshops before the studystarted, followed up by regular workshops and teammeetings. This was done to further improve theirintervention and assessment skills, to explain the trialprocedures, and to improve adherence to the protocol.Definitions, perceptions and practices related toclient-centred practice [13,19] were often discussed.This was done because it has been found in rehabilita-tion settings, that although occupational therapistsdescribed their own practice as being client-centred,their clients had experienced only little or no activeinvolvement in goal setting and no awareness of a‘client-centred approach’ [53]. In addition, the firstauthor, also an experienced occupational therapist,was available for questions and discussions through-out the study period. An expert on the AMPS organ-ized three workshops with the occupational therapistsand was available for questions throughout the studyperiod.

The two research occupational therapists per-formed the baseline assessments and delivered theICC-OT. They filled out a standard client record aftereach session of ICC-OT to record date, duration, andbrief details about the tasks and activities workedon, whether acquisitional, adaptive or restorativeapproaches were used, and which assistive deviceswere introduced. They also recorded any harms orunintended effects. They did not interact with anyoccupational therapists who served the Usual-Practicegroup. The four assessors were assigned by conveni-ence to perform the 3-month and the 6-monthassessments. None of the assessors had deliveredhomecare re-ablement to the older adults that theyassessed.

Masking

The study was assessor-masked (single blind). Thebaseline assessments were carried out before random-ization. The assessors who undertook the 3- and6-month assessments were not informed about theparticipants’ allocation status or their results fromprevious assessments. The participants could not bemasked at the 3- and 6-month assessments but wereurged not to discuss their allocation status with theirassessors, and they were not shown the results of theirprevious assessments.

Data management and statistical methods

The sample size was based on an MCID of 2 pointson the COPM [37], a standard deviation (SD) of 2.22

[54], an alpha level of 0.05, and a power of 80%.Twenty participants in each group were required.Allowing for a 20% attrition rate [55] and with thewish to perform several secondary analyses, the studyaimed at including 120 participants. To ensure a reli-able dataset, data were entered twice in Epi-data [56]by two independent researchers. In the case of anincongruence, the original data form was consulted toestablish the correct result. Stata 12 was used for theanalyses [57]. The significance level was set at 0.05.The analyses were performed by original assignedgroups (intention-to-treat) on all available data. Atbaseline, data were presented per randomized groupby mean and SD or number and percentage. Thebetween-group differences in change from baseline to3 months and from baseline to 6 months on theCOPM performance, COPM satisfaction, the AMPSand the SF-36 were presented with 95% confidenceintervals (CIs) and tested with t-tests for independentsamples. The within-group changes from baseline to 3months and from baseline to 6 months were pre-sented with SDs and tested with t-tests for pairedsamples. Exploratory multiple linear regression analy-ses were used to adjust the primary outcome for pos-sible assessor influence, and to explore possible effectmodification concerning age, general health and sex.Chi-square tests and tests for trend were usedto analyze categorical and ordinal outcomes.Correlations between two outcomes were explored bySpearman’s rho.

Ethics

Laws and regulations according to the Declaration ofHelsinki were followed, and special attention wasdrawn to consent and confidentiality [58]. Informedconsent was given by all participants, and the studywas approved by the Danish Data Protection Agency(trial identifier Jnr 2012-52-0049). The ScientificEthics Committee of Central Denmark Regiondeemed the study not to fall under the category bio-medical research, and further ethical approval wastherefore not required (query number 153/2012). Thearticle complies with the CONSORT statement fortransparent reporting [59].

Trial registration

The study was registered through Current ControlledTrials, trial identifier ISRCTN93873801 DOI 10.1186/ISRCTN93873801 [60]. No important changes weremade to methods after trial commencement.


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Results

Figure 2 illustrates the participant flow. Of the 942 olderadults assessed for eligibility, 119 finally enrolled (take-up rate 18%). The most common reasons given for notparticipating were directly related to health issues orexpressed as an anticipation that participation would betoo onerous. Some older adults did not have any prob-lems that they wanted to work on. Non-participantswere on average 4.4 years older than participants (95%CI 2.76 to 6.05), t-test: p< 0.001. There was no differ-ence in sex distribution, chi-square test: p¼ 0.74. Thebetween-group differences in numbers lost to follow-upat 3 months and at 6 months were not statistically sig-nificant, chi-square test: p¼ 0.21 and 0.35, respectively.

Table 2 presents demographics and baseline meas-urements for both groups. All experienced some diffi-culty with their occupational performance at baseline.Participants in the ICC-OT group received 43minutes(median) of personal care and/or practical help perweek, and participants in the Usual-Practice groupreceived 34minutes (median) per week, Wilcoxon’srank sum test: p¼ 0.46. The participants’ SF-36GH

(General Health) score was significantly lower in bothgroups than the score of 62.55 (SD 22.5) derived fromDanish norm data for men and women 75þ years old[47], t-test: p< 0.001. Those who were lost to follow-upat the 3-month assessment had somewhat poorer per-ceived general health at baseline than those who werereassessed. They did not differ on other demographicsand baseline measurements. All participants had at leastone health issue, which substantially affected theiroccupational performance. The 215 health issuesreported at baseline were assigned to the followingcategories [39,40]: ‘orthopaedic/musculoskeletal’ 109(51%), ‘medical’ 51 (24%), ‘neurologic stroke/non-stroke’ 30 (14%), ‘sensory/falls’ 14 (6%), ‘psychiatric’nine (4%), ‘impairment of learning’ one (0.5%), and‘unknown’ one (0.5%).

Primary hypothesis, change from baseline to the3-month assessment on COPM performance

Table 3 shows that the primary hypothesis of thestudy was confirmed, as the ICC-OT group improved

Figure 2. Participant flow.


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their COPM performance from baseline to the 3-month assessment statistically significantly more thanthe Usual-Practice group: difference 1.26 points (95%CI 0.50 to 2.02), t-test: p¼ 0.001.

An exploratory multiple linear regression analysisadjusting for assessors at baseline and at the 3-monthassessments, revealed a slightly smaller difference: 1.12points (95% CI 0.35 to 1.89), p¼ 0.005. The between-group difference in means on the COPM performancescore at the 3-month assessment was explored, too;the conclusions remained similar to the primary anal-yses on change-scores. (This explorative analysis wasapplied to all hypotheses. The results as well as themean scores on all outcomes at 3 and 6 months arefound in Appendix 1).

Figure 3 illustrates the main result: The COPMperformance scores were, in general, higher at the 3-month assessment than at baseline, and this wasmostly due to improvements in the ICC-OT group.Low correlations were found between baseline and 3-month scores: ICC-OT group, Spearman’s rho: 0.12,p¼ 0.43, Usual-Practice group, Spearman’s rho: 0.17,p¼ 0.17.

Table 3 also presents the within-group changesfrom baseline to 3 months. A closer examination ofthese changes revealed statistically significantimprovements in the mean scores within both groups.Exploratory analyses at participant level concerningan MCID of 2 points on the COPM performancescore were carried out. The analyses showed that inthe ICC-OT group 22 participants (48%) improved

and one (2%) declined, while in the Usual-Practicegroup eight (15%) improved and four (8%) declined.A similar analysis concerning an MCID of 1.4 pointsshowed that in the ICC-OT group 28 participants(61%) improved and two (4%) declined, while in theUsual-Practice group 18 (35%) improved and seven(13%) declined. Tests for trend confirmed that statis-tically significantly more participants in the ICC-OTgroup than in the Usual-Practice group improvedtheir COPM performance by an MCID of 2 points ormore, p< 0.001, and by an MCID of 1.4 points ormore, p¼ 0.007.

Figure 4(a,b) illustrates exploratory analyses con-ducted concerning age and general health in relationto COPM performance, using multiple linear regres-sion. Age did not modify the between-group differen-ces in change from baseline to 3 months in COPMperformance, p¼ 0.99, and age did not independentlyinfluence the change, p¼ 0.42 (see Figure 4a). In con-trast, general health at baseline tended to modify thebetween-group differences in change, seen as the dif-ferent directions of the slopes in Figure 4(b).However, the slopes were not statistically significantlydifferent, p¼ 0.073. The between-group difference inchange among participants with an SF-36GH scorefrom 50 and up was 2.11 points (95% CI 0.92 to3.31), whereas among participants with an SF-36GHscore below 50 the difference was only 0.59 points(95% CI -0.42 to 1.60). However, the differences inchange between participants with higher and lowergeneral health were not statistically significant,p¼ 0.057.

An exploratory regression analysis concerning sex(not illustrated) showed that the between-group differ-ence in change from baseline to 3 months in COPMperformance was 1.77 points (95% CI 0.35 to 3.19) inmen and 1.04 points (95% CI 0.13 to 1.95) in women.Nevertheless, this difference between men and womenwas not statistically significant, p¼ 0.39. Sex did notindependently influence the change: the difference inchange between men and women was 0.12 points(95% CI �0.71 to 0.96), p¼ 0.77.

Secondary hypotheses, changes from baseline to3 months and to 6 months

Table 3 shows that at 3 months, no between-groupdifferences in change were found concerning any ofthe secondary hypotheses (Secondary hypothesis 1to 5). The within-group improvements in COPMsatisfaction and on the AMPS motor scale were

Table 2. Demographics and baseline measurements for bothgroups.

Mean (SD)when not otherwise reported

ICC-OT groupn¼ 59

Usual-Practicegroupn¼ 60

Age 78.4 (9.4) 76.8 (6.8)Women, n (% ) 45 (76 %) 41 (68 %)Living alone, n (%) 49 (83 %) 48 (80 %)1 diagnosis, n (%) 20 (34 %) 18 (30 %)2 diagnoses, n (%) 28 (47 %) 33 (55 %)�3 diagnoses, n (%) 11 (19 %) 9 (15 %)Personal care or practical help, n (%) 46 (78 %) 49 (82 %)Meal delivery, n (%) 16 (27 %) 12 (20 %)COPM performance 3.36 (1.13) 3.41 (1.24)COPM satisfaction 3.74 (1.55) 3.38 (1.43)AMPS motor 0.57 (0.64) 0.73 (0.63)AMPS process 0.62 (0.35) 0.71 (0.34)SF-36 General health score# 44.95 (19.94) 41.63 (19.11)SF-36 PCS (physical) 29.00 (9.71) 28.96 (9.15)SF-36 MCS (mental) 50.43 (11.82) 46.26 (12.70)

COPM: Canadian Occupational Performance Measure; AMPS: Assessmentof Motor and Process Skills; SF-36: Short Form 36 Health Survey.#Standardised score, range 0–100, better score denotes better generalhealth. PCS: physical component summary; MCS: mental componentsummary; ICC-OT: Intensive Client Centred Occupational Therapy.


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https://doi.org/10.1080/0284186X.2017.1424236

Table3.

Occup

ationalp

erform

ance

andhealth

relatedqu

ality

oflife.With

in-group

changesandbetweengrou

pdiffe

rences

inchange.

ICC-OTgrou

pUsual-Practicegrou

pBetweengrou

pdiffe

rences

Assessmenta

Change

from

baselineto

3mon

thsb

(SD)

n¼46

COPM

n¼36

AMPS

n¼46

SF-36

Change

from

baseline

to6mon

thsb

(SD)

n¼44

COPM

n¼35

AMPS

n¼43

SF-36

Change

from

baseline

to3mon

thsb

(SD)

n¼52

COPM

n¼44

AMPS

n¼50

SF-36

Change

from

baseline

to6mon

thsb

(SD)

n¼49

COPM

n¼38

AMPS

n¼49

SF-36

Difference

inchange

from

baselineto

3mon

thsc

(95%

CI)

Difference

inchange

from

baselineto

6mon

thsc

(95%

CI)

Prim

aryou

tcom

eCO

PMPerformance

Rang

e1;10

1.87��

�(SD1.84)

1.42��

�(SD1.91)

0.61�

(SD1.94)

0.44

(SD1.55)

Primaryhypo

thesis

1.26

(0.50to

2.02)

p¼0.001��

Second

aryhypo

thesis6

0.98

(0.27to

1.70)

p¼0.008��

Second

aryou

tcom

esCO

PMSatisfaction

Rang

e1;10

1.83��

�(SD2.06)

2.08��

�(SD2.11)

1.12��

�(SD1.97)

0.99��

�(SD1.82)

Second

aryhypo

thesis1

0.71

(�0.09

to1.52)

p¼0.08

Second

aryhypo

thesis7

1.09

(0.28to

1.90)

p¼0.009��

AMPS

Motor

Rang

e�3

;40.33�

(SD0.82)

0.44��

�(SD0.68)

0.28�

(SD0.74)

�0.00

(SD0.62)

Second

aryhypo

thesis2

0.05

(�0.30

to0.39)

p¼0.79

Second

aryhypo

thesis8

0.44

(0.14to

0.74)

p¼0.005��

AMPS

Process

Rang

e�4

;30.17

(SD0.53)

0.17�

(SD0.49)

0.07

(SD0.51)

�0.02

(SD0.42)

Second

aryhypo

thesis3

0.11

(�0.13

to0.34)

p¼0.37

Second

aryhypo

thesis9

0.19

( �0.02

to0.40)

p¼0.08

SF-36

PCS

Rang

e0;100

�0.47

(SD7.30)

�2.14

(SD7.5)

�0.48

(SD7.09)

�0.96

(SD8.63)

Second

aryhypo

thesis4

0.01

(�2.90

to2.93)

p¼0.99

Second

aryhypo

thesis10

�1.19(�

4.56

to2.19)

p¼0.49

SF-36

MCS

Rang

e0;100

3.24

(SD12.56)

3.28

(SD11.91)

1.47

(SD10.82)

2.83

(SD13.03)

Second

aryhypo

thesis5

1.77

(�6.52

to2.97)

p¼0.46

Second

aryhypo

thesis11

0.45

(�4.75

to5.65)

p¼0.86

a Range,allassessmenttools:high

erscores

aremorepo

sitive.

COPM

:CanadianOccup

ationalPerformance

Measure;A

MPS:A

ssessm

entof

Motor

andProcessSkills;SF-36:

ShortForm

36Health

Survey;P

CS:P

hysical

Compo

nent

Summary;MCS:M

entalC

ompo

nent

Summary;ICC-OT:IntensiveClient-Centred

Occup

ationalT

herapy.

bPairedt-tests.

c Unp

airedt-tests.

� The

results

werestatisticallysign

ificant

at0.05� ,

at0.01��

,orat

0.001��

level.


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statistically significant in both groups. Changes frombaseline to 6 months in COPM performance(Secondary hypothesis 6), COPM satisfaction(Secondary hypothesis 7) and on the AMPS motorscale (Secondary hypothesis 8) were statistically sig-nificantly larger in the ICC-OT group than in theUsual-Practice group.

Discussion

The primary hypothesis regarding the effectiveness ofICC-OT in the home was confirmed: ICC-OT signifi-cantly improved the participants’ own perceptions oftheir occupational performance compared to usualpractice. This principal finding is consistent with

Figure 3. COPM performance at baseline and at 3 months.

Figure 4. (a,b) Exploratory analyses of age and health status' influence on change in COPM from baseline to 3 months.


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previous studies of the effect of occupation-based OTin the homes of older adults with stroke, Parkinson’sdisease or multiple chronic health issues [26,28–31].The initial COPM performance score (Table 2) wasclose to findings in other European studies amonghome-dwelling older adults [31,61,62]. The between-group difference in improvement at 3 months onCOPM performance of 1.26 points in the presentstudy (Table 3) was comparable to a between-groupdifference in improvement of 1.2 points found in aDutch study of occupation-based OT for older adultswith Parkinson’s disease [31]. As older adults oftenperform activities of daily living near their maximalcapabilities [63], it may be hypothesized that evensmall improvements in occupational performance canbe of importance to their everyday life. In the presentstudy, the mean change in COPM performance at 3months of 1.87 points in the ICC-OT group was closeto or exceeding proposed MCIDs of 2 and 1.4 points[37,38], and a statistically significantly higher propor-tion of participants in the ICC-OT group than in theUsual-Practice group achieved these MCIDs. Theimportance of the principal findings on COPM per-formance in the ICC-OT group are also strengthenedby concurrent improvements in COPM satisfactionthat were close to an MCID of 2 points and byimprovements on the AMPS motor scale thatexceeded an MCID of 0.3 points [39]. The latter resultindicates that there had been an observable change inthe participants’ quality of ADL task performancerelated to motor skills. The robustness of the outcomeconcerning our primary hypothesis is supported bythe fact that the effectiveness pertained to both maleand female participants and to participants of all ages(60 to 96 years). Thus, we have reason to believe thatthe achieved and statistically significant improvementsin the ICC-OT group were of clinical and individualimportance to a large number of the participants.

The ICC-OT was effective, even in a group where80% of the participants were already receiving home-care services at the time of inclusion. A Danish eco-nomic evaluation of homecare re-ablement from 2016suggested that this approach was more successfulamong first-time applicants for homecare than amongolder adults who had received homecare prior tohomecare re-ablement [64]. Therefore, as only 20% ofthe participants in the present study were first-timeapplicants, the effect would probably have beengreater if more first-time applicants for homecareservices had been included.

Six months post baseline, the achieved improve-ments were still larger in the ICC-OT group than in

the Usual-Practice group. The between-group differ-ences in improvement on COPM performance,COPM satisfaction, and the AMPS motor scale werealso statistically significant in favor of the ICC-OTgroup. The positive results on the COPM at 6 monthsare in line with results of home-based OT for olderadults with Parkinson’s disease [31] and indicate thatthe strategies learned through OT can be successfullyimplemented in everyday life.

Our exploratory analysis indicated a larger effect ofICC-OT among participants who scored �50 on theSF-36GH score at baseline. These findings should befurther investigated, as it would be of help if olderadults with a large potential for improvement fromICC-OT could be identified. In addition, our explora-tory findings indicate a need to develop interventionsfor older adults with a smaller potential for improve-ment. In this subgroup, improved occupational per-formance may not be the only success criterion;maintenance of occupational performance may be anappropriate aim, too. Further research may showwhether embedding periods of ICC-OT within home-care re-ablement programs and implementing a morenuanced definition of the aims could accommodatethe rehabilitation needs of older adults at lower levelsof general health.

Strengths and limitations

The validity of the results was strengthened by therandomized controlled design, the use of assessmentsvalidated for older populations, experienced occupa-tional therapists, blinding of the assessors, and theeducational workshops before and during the study.Meanwhile, the study also had some limitations.

The take-up rate of 18% was low. The refusersmost often explained their decision with reference totheir health. Nevertheless, refusers may have declinedthe ICC-OT treatment for several additional reasons.First, they may have been opposed to specific detailsabout the ICC-OT. Second, they may have been disin-clined to participate in a scientific study per se, eitherbecause their involvement implied repeated assess-ments or because they were uncertain whether theywould be assigned to either of the two groups. Suchbarriers to participating in RCTs have previously beenreported [65], and a qualitative pilot study amongolder adults before the present study could have ledto adjustments of the design, the content and theinformation material [66]. This could possibly haveresulted in a better take-up rate. Another reason forrefusing participation in the study may be the fact,touched upon in the introduction, that some older


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adults feared that they would lose their homecareassistants if they should become independent as aresult of the ICC-OT [5].

The total loss to follow-up was 21.8% and highestamong participants with lower general health. A largeloss to follow-up is often seen in studies among olderadults and may be difficult to avoid due to fluctuatinghealth in this age group [55]. The difference in loss tofollow-up was not statistically significant between thetwo groups. Nevertheless, many refusers referred tohealth issues as their reason for not participating, andthe difference in change from baseline to 3 monthswas smaller in the subgroup with low general health.Therefore, one may speculate that if more participantswith low general health had participated in the studyand completed the 3-month assessment, a smallergeneral effect may have been detected, suggesting thatthe participants had an intuitive self-sense as towhether they would benefit.

A large majority of the participants were livingalone, the rest with a spouse. In many countries/cul-tures, it is more common for older adults to live withtheir family than it is in Denmark. An active buy-inof spouse or family was not emphasized in the ICC-OT; yet they could be included in the therapy if theolder adult wished to. Other studies of home-basedinterventions for older adults have focused more onincluding primary caregivers [e.g. 30,31], and futurestudies of ICC-OT may explore how the presence offamily may influence the participants’ motivation andoutcome.

In the Danish welfare state, services such as home-care, home-based OT, assistive devices etc. are freewhen older adults meet certain criteria [10]. If theparticipants were required to pay for some of theseservices themselves, for instance assistive devices, theymight have declined them, and consequently, theeffect of the ICC-OT might have been smaller.

The participants in the present study were notblinded to their group allocation, since, as pointed outin other randomized controlled trials within rehabili-tation, the behaviorally based intervention (the ICC-OT) required their active participation [67].To diminish the difference in the anticipation of‘effect’ among the participants, we could have placedmore emphasis on the fact that we tested two differ-ent approaches instead of stressing that we tested aspecial program versus usual practice [68].

A warning has been raised that therapist’s and otherhealth workers’ practices can be heavily influenced bydiscourses of ‘normal ageing’ linked to inevitabledeclines in physical and cognitive abilities, and with a

heavy focus on the promotion of safety [69], whichmay lead to not entirely client-centred practices. Suchissues were discussed with the research occupationaltherapists throughout the present study. Nevertheless,the therapists’ individual experiences with rehabilita-tion of older adults and the fact that most participantswere already receiving homecare services may haveinfluenced the focus of the ICC-OT. Still, the breadthof activities worked on during ICC-OT, and the factthat many of the tasks and activities worked on couldnot be addressed through usual practice, suggest thatthe participants in the ICC-OT group were, indeed,given more free choice of goals than those in theUsual-Practice group, who received homecare re-able-ment. This reflects the client-centred practiceembedded in the ICC-OT [13,19].

The participants in the Usual-Practice group hadalso improved on the primary outcome at 3 months,although to a lesser degree than the ICC-OT group.No participants in the Usual-Practice group receivedICC-OT, and measures were taken to avoid that thetreatment principles of the ICC-OT should inspireoccupational therapists working with the Usual-Practice group. Nevertheless, the initial COPM inter-view was performed with all participants before ran-domization, and it has been pointed out that thisinterview may have a therapeutic effect in itself, sinceit increases awareness and motivation [31,61]. Thus, achange process may also have started in the Usual-Practice group, which may have reduced the differ-ence in outcome between the two groups.

The primary analysis was performed on the changescores between baseline and 3 months, as recom-mended in the COPM manual [20]. This procedure isexpected to create estimates of high precision.However, due to the low correlations between thebaseline and 3-month scores in the present study, nar-rower confidence intervals were found on thebetween-group differences in 3-month scores than onthe differences in change scores. Thus, if low correla-tions between baseline and 3-month scores on theCOPM is a general trend, and if groups to be com-pared are expected to be similar at baseline, as inRCTs, higher statistical power can be obtained bycomparing post intervention scores than changescores.

An issue worth discussing is how to interpret theresults of an RCT within OT. The outcome measuresCOPM and AMPS were chosen to focus on problemsrelevant to the participants, in line with the client-centred approach of ICC-OT. A caveat concerning theCOPM in relation to client-centredness has been


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expressed by Hammell [70] who points out that thecategorisations self-care, productivity and leisure werenot derived from clients’ experiences and do not fullyreflect clients’ experiences of occupational engagementand a meaningful life. As an answer to this, research-ers may consider ways of supplementing the interpret-ation of attained changes in future studies, e.g. byincluding a qualitative evaluation to learn more aboutparticipants’ own perceptions of how achievedchanges may affect their occupational engagementduring and after the intervention [66]. In the presentRCT, two MCIDs were used to interpret the primaryoutcome concerning between-group differences inchange as well as within-group improvements andindividual changes. More research has been called forto examine MCIDs in relation to the COPM [37,38].In addition, it has been questioned whether it ismeaningful to infer the amount of change that isdetectable or important to individuals based on agroup average [71]. Secondary outcomes were used tosupplement the interpretation of the primary result.We did not assess whether the participants werebecoming independent of help, as this was not theexpressed aim of the ICC-OT. Yet it is a question ofinterest for municipal decision makers, who allocatescarce healthcare resources. We therefore recommendembedding concurrent economic evaluations in futureRCTs addressing the effectiveness of OT in a home-care setting [66]. No follow-up was performed after 6months, and future studies may explore long-termeffectiveness of ICC-OT.

Conclusions

In-home ICC-OT, in which older adults with variouschronic health issues intensively practised the activ-ities they valued the most for up to 11 weeks, supple-mented by free access to assistive devices and minorhome modifications, effectively improved their self-rated occupational performance at 3 months and6 months post baseline. The participants’ satisfactionwith their occupational performance also improved, aswell as the observed quality of their occupational per-formance. The ICC-OT was effective regardless of sexor age, yet participants with the lowest general healthimproved to a lesser degree. The observation thatthere was still a benefit 6 months post baseline indi-cates that the improvements achieved and the strat-egies learned were successfully implemented ineveryday life. The results may be generalized tohome-dwelling older men and women aged 60þ, wholive alone or with a spouse in a Scandinavian

homecare context and experience occupational per-formance problems due to various health issues.

Clinical implications

The results of the present study are an important con-tribution to the emerging evidence base concerningintensive and client-centred OT for older adults withoccupational performance problems. These resultsshould therefore be taken into consideration whenplanning rehabilitative OT services and homecare re-ablement for home-dwelling older adults.

Acknowledgements

The occupational therapists Karen Andersen, AnetteBjerring, Dorte Sølund Hansen, Karin Breiner Henriksen,Lene Ifversen, Jytte Jakobsen, Birgitte Krogh Jespersen, ZitaJespersgaard, Louise Møldrup Nielsen, Hanne Pedersen,Helle Søndergaard Thomsen, senior consultant Nils Høgel,and the steering committee from The Municipality ofRanders and VIA University College are greatly acknowl-edged for their participation and support.

Disclosure statement

The authors report no conflicts of interest.

Funding

The study has received financial, material and other supportfrom The Tryg Foundation (Grant number J.nr.7-11-1343);The Municipality of Randers; VIA University College;Aarhus University, Department of Public Health; TheDanish Association of Occupational Therapists (Grant num-ber FF 1 13 - 10); and DEFACTUM, Central DenmarkRegion. The funders had no influence on the design or theresults of the study.

ORCID

Tove Lise Nielsen http://orcid.org/0000-0002-1253-2413Helene Polatajko http://orcid.org/0000-0003-1990-5371Claus Vinther Nielsen http://orcid.org/0000-0002-2467-1103

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App

endix1.

Occup

ationalp

erform

ance

andhealth

relatedqu

ality

oflife.

Meanscores

andbe

tweengrou

pdifferen

cesat

3an

d6mon

ths

ICC-OTgrou

pUsual

practicegrou

pBe

tweengrou

pdifferen

ces

(exploratory

analyses)

Assessmentsa

3mon

ths

COPM

n¼46

AMPS

n¼36

SF-36n¼46

6mon

ths

COPM

n¼44

AMPS

n¼35

SF-36n¼43

3mon

ths

COPM

n¼52

AMPS

n¼44

SF-36n¼50

6mon

ths

COPM

n¼49

AMPS

n¼38

SF-36n¼49

3mon

ths

Betweengrou

pdiffe

rences#(95%

CI)

6mon

ths

Betweengrou

pdiffe

rences#(95%

CI)

Prim

aryen

dpo

int

COPM

Performance

Rang

e1;10

5.29

(SD1.73)

4.87

(SD1.73)

4.08

(SD1.63)

3.93

(SD1.78)

Primaryhypo

thesis

1.21

(0.54to

1.88)

p<0.001��

Second

aryhypo

thesis6

0.94

(0.21to

1.66)

p¼0.012�

Second

aryen

dpo

ints

COPM

Satisfaction

Rang

e1;10

5.61

(SD1.75)

5.87

(SD1.91)

4.49

(SD2.04)

4.38

(SD2.22)

Second

aryhypo

thesis1

1.13

(0.36to

1.89)

p¼0.004��

Second

aryhypo

thesis7

1.49

(0.63to

2.35)

p<0.001��

AMPS

Motor

Rang

e�3

;40.88

(SD0.67)

0.94

(SD0.75)

1.00

(SD0.62)

0.78

(SD0.56)

Second

aryhypo

thesis2

�0.12(�

0.41

to0.16)

p¼0.39

Second

aryhypo

thesis8

0.17

(0.14to

0.47)

p¼0.28

AMPS

Process

Rang

e�3

;40.78

(SD0.49)

0.82

(SD0.51)

0.77

(SD0.48)

0.70

SD0.40)

Second

aryhypo

thesis3

0.01

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Appendix 2

Article 2

Full Terms & Conditions of access and use can be found athttp://www.tandfonline.com/action/journalInformation?journalCode=iocc20

Download by: [Statsbiblioteket Tidsskriftafdeling] Date: 30 August 2017, At: 06:46

Scandinavian Journal of Occupational Therapy

ISSN: 1103-8128 (Print) 1651-2014 (Online) Journal homepage: http://www.tandfonline.com/loi/iocc20

What are the short-term and long-term effectsof occupation-focused and occupation-basedoccupational therapy in the home on older adults’occupational performance? A systematic review

Tove Lise Nielsen, Kirsten Schultz Petersen, Claus Vinther Nielsen, JanniStrøm, Monica Milters Ehlers & Merete Bjerrum

To cite this article: Tove Lise Nielsen, Kirsten Schultz Petersen, Claus Vinther Nielsen, JanniStrøm, Monica Milters Ehlers & Merete Bjerrum (2017) What are the short-term and long-termeffects of occupation-focused and occupation-based occupational therapy in the home on olderadults’ occupational performance? A systematic review, Scandinavian Journal of OccupationalTherapy, 24:4, 235-248, DOI: 10.1080/11038128.2016.1245357

To link to this article: http://dx.doi.org/10.1080/11038128.2016.1245357

Published online: 21 Oct 2016. Submit your article to this journal

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REVIEW ARTICLE

What are the short-term and long-term effects of occupation-focused andoccupation-based occupational therapy in the home on older adults’occupational performance? A systematic review

Tove Lise Nielsena,b, Kirsten Schultz Petersenc, Claus Vinther Nielsend, Janni Strøma,e,Monica Milters Ehlersa and Merete Bjerruma,f

aDivision of Rehabilitation, DEFACTUM, Central Denmark Region, Aarhus, Denmark; bVIA Department of Occupational Therapy, Aarhus,Denmark; cDepartment of Health Science and Technology, University of Aalborg, Denmark; dDepartment of Public Health, Section forClinical Social Medicine and Rehabilitation, Aarhus University, Denmark; eSilkeborg Regional Hospital, Interdisciplinary Research Unit,Elective Surgery Center, Denmark; fDepartment of Public Health, Section for Nursing Science, Aarhus University, Denmark

ABSTRACTBackground: There is a lack of evidence-based knowledge about the effectiveness of home-based OT for older adults aimed at improving occupational performance by practicing activitiesand tasks.Aim: This review synthesizes and discusses evidence for the effectiveness of occupation-focusedand occupation-based OT for older adults at home.Material and methods: Peer-reviewed quantitative papers were included. Participants:� 60-year-old adults with functional limitations. Intervention: OT aiming at improving occupationalperformance, primarily through the practice of activities and tasks. Outcome: Occupational per-formance. Context: Home. Three reviewers critically appraised 13 of 995 detected papers.Extracted data were presented and summarized descriptively.Results: Eight high-quality papers showed that occupation-focused and occupation-based OTusing cognitive, behavioral and environmental strategies may significantly improve occupationalperformance in older, home-dwelling adults with physical health problems. Maintaining achievedimprovements was a consistent challenge.Conclusions and significance: Evidence suggests that older adults’ occupational performancecan be significantly improved through low-intensity occupation-focused and occupation-basedintervention. It is recommended to develop and test high-intensity OT programs and mainten-ance programs.

ARTICLE HISTORYReceived 6 May 2016Revised 4 July 2016Accepted 3 October 2016

KEYWORDSActivities of daily living;effectiveness; home-based;home-dwelling; instrumen-tal activities of daily living;occupation; rehabilitation

Introduction

Older adults’ occupational performance may be ham-pered due to acute events, slowly progressive diseases,impaired body function and structure, and environ-mental and personal factors [1–5]. The occupationalperformance problems encountered by older adultsare all-encompassing, pertaining to activities of dailyliving (ADL: taking care of one’s body), instrumentalactivities of daily living (IADL: activities to supportdaily life in home and community), leisure activities,social participation and mobility, among others[1,4,6–8]. Older adults generally wish to stay activeand independent of help and to be able to continueliving in their own homes as long as possible [9,10],but the above-mentioned problems can influence theirsurvival, health, service utilization and quality of life[1,4,11]. Promoting older adults’ ageing in place (i.e.

remaining in the community with some level of inde-pendence rather than in residential care) is a majorcurrent aim for policy makers and service providerswho anticipate dramatic increases in welfare costsdue to ongoing demographic changes [9,12]. Home-based rehabilitation is one way of pursuing this aim,and occupational therapists play a key role with theaim to improve and maintain older adults’ safe andindependent occupational performance [13–15].For this review, home-based occupational therapy(OT) is defined as OT substantially performed byoccupational therapists in the older adults’ homes andother relevant natural or built environments but not ininstitutional settings. The home setting for OT hasbeen perceived as beneficial by older adults as it ena-bles them to engage in life-relevant and meaningfuloccupations in their natural surroundings [16–18]. The

CONTACT Tove Lise Nielsen [email protected] Department of Occupational Therapy, VIA University College, Hedeager 2, DK-8200 Aarhus N, Denmark� 2016 Informa UK Limited, trading as Taylor & Francis Group

SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY, 2017VOL. 24, NO. 4, 235–248http://dx.doi.org/10.1080/11038128.2016.1245357

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home thus provides optimal opportunities for so-calledoccupation-focused and occupation-based OT, oftenpracticed together, where occupational performance isassessed and practicing of activities and tasks acts asboth the aim and the primary therapeutic means. Theconcepts occupation-focused and occupation-based OTas explained by Fisher [19,20] are schematically pre-sented in relation to older adults in Table 1.

While practicing occupation-focused and occupa-tion-based OT, the occupational therapists may usemodels of acquisitional and/or adaptive occupation[19] with associated intervention-strategies, for instanceadapted methods of doing, assistive technology andenvironmental modifications [14,15,19]. Home-basedOT may also use other non-occupation-focused ornon-occupation-based models, such as educationalmodels and models aiming at improving impaired bodyfunctions, e.g. through rote practice [19,20]. Olderadults and other client groups often find occupation-based OT more meaningful, motivating and satisfyingthan rote practice [21,22], which supports the use ofoccupation-based OT [20].

In accordance with professional guidelines and con-temporary understandings of evidence-based health-care, occupational therapists are obliged to practice inways that are supported by the most up-to-date evi-dence available [23,24]. This will be to the benefit ofindividual clients and of society as a whole. A properevidence base may be obtained from literature reviewsthat synthesize the best current evidence within a spe-cific area [24–26]. An initial broad literature search forprevious reviews about the effectiveness of OT forolder adults with different health problems revealedpositive effects on a number of outcomes: falls preven-tion [27–30]; maintenance of ADL and IADL perform-ance [29–33]; improvements in ADL, IADL, leisure,social participation, perceptions of driving skills andquality of life [28–32,34–36]; and cost-effectiveness[27,28]. Nevertheless, the reviews vary much in termsof practice settings and involved professions. Thetherapeutic strategies are often not clearly described,and only two of the above-mentioned reviews exclu-sively explore home-based interventions [28,36].

Older adults are exposed to many factors that chal-lenge their level of functioning over time [6]. Whenthey undergo a rehabilitation program like home-

based OT, it is therefore of interest to focus not onlyon assessing the immediate outcomes at the end of anintervention, the short-term effectiveness. Long-termeffectiveness should be assessed too to show to whichdegree the achieved improvements and new strategiesare integrated in everyday life and maintained afterthe rehabilitation period. While no specific definitionexists of when long-term effectiveness of OT for olderadults should be assessed, follow-up results six to ninemonths after the end of an intervention are oftenreported in the research literature. Only one of theabove-mentioned reviews specifically reports theshort-term and long-term effectiveness of OT [30].

To date, no review has been conducted of theresearch literature to determine the short-term andlong-term effectiveness of occupation-focused andoccupation-based OT for older adults at home. Amore specific evidence base concerning this type ofOT in the homes of older adults may inform unipro-fessional OT rehabilitation practice as well as multi-professional home-care reablement practice. The aimof the present systematic review is therefore to answerthe following review question: What are the short-term and long-term effects of occupation-focused andoccupation-based OT in the home on older adults’occupational performance?

Material and methods

In accordance with guidelines from The Joanna BriggsInstitute [37], this systematic review was conducted inthe following seven stages: (1) Formulation of reviewquestion, (2) Formulation of inclusion criteria andsearch strategy, (3) Performance of literature search,(4) Assessment of relevance, (5) Assessment of meth-odological quality, (6) Data extraction and (7) Dataanalysis and synthesis.

Inclusion criteria, search strategy andperformance of literature search

The Population Interventions Comparators Outcomes(Context) (PICO(C)) model was used to guide thestructuring of the review question, to frame the inclu-sion and exclusion criteria and to plan the searchstrategy [37–39]. Inclusion and exclusion criteria

Table 1. Occupation-focused and occupation-based interventions for older adults.Occupation-focuseda Occupation-baseda

Assessments The older adult’s occupational performance is the focus ofassessments

The older adult is engaged in real-life activities and tasksduring assessments

Interventions Strategies can vary. Improvement of occupational perform-ance is the intended outcome and proximal focus

The older adult is engaged in real-life activities and tasksduring interventions

a[inspired by 19,20].


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concerning characteristics of included papers, studypopulation, interventions, comparators, outcomes andcontext are presented in detail in Table 2.

The criteria concerning the population excludedolder adults with dementia and cancer at a terminalstate since they are most often referred to other kindsof OT than those in question in the present review.The criteria concerning the interventions and the con-texts ensured that emphasis was given to individual,occupation-focused and occupation-based OT deliv-ered in and around the home.

The systematic literature search was conducted byTLN in cooperation with science librarians fromAarhus University Library and VIA University CollegeAarhus. Seven online databases: Cochrane, PubMed,Embase, CINAHL, Psych INFO, SveMedþ and OTSeeker were searched. Searches were performedbetween 1 August and 15 September 2015 to identifypeer-reviewed, published research papers. A three-stepsearch was performed. Firstly, to identify keywords, asearch was performed in Cochrane and PubMed withkeywords based on knowledge of the field. Additionalkeywords were identified in relevant titles and abstractsand by examining how papers found were indexed inbibliographic databases. Secondly, database-specificsearches were implemented after consulting the the-saurus of each database. Initial keywords and anexample of the search are presented in Appendix 1.Thirdly, the reference lists of all papers retrieved forappraisal were scanned for additional studies.

Assessment of relevance and methodologicalquality

A three-step assessment was performed. Firstly, alltitles and abstracts (N¼ 995) were scanned for

relevance by TLN, using a template created from theinclusion and exclusion criteria; and all obviouslyirrelevant studies were excluded. Secondly, TLN readthe remaining papers (N¼ 30) in full text and excludedstudies that did not meet the inclusion criteria. Whendoubt arose, senior researchers (CVN, KSP or MB)were consulted and agreement was achieved throughconsensus discussion. Three mixed methods studieswere excluded in this phase as they were pilot/feasibil-ity studies. Thirdly, the remaining papers (N¼ 13)were critically appraised for methodological quality bythree independent reviewers (TLN, CVN and either JSor MME), using the standardized critical appraisalinstruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and ReviewInstrument (JBI-MAStARI) [37]. Before the appraisal,it was decided that at least 75% of the criteria of theJBI-MAStARI checklist should be satisfactorily met fora paper to be included. Any disagreements betweenreviewers were resolved through consensus discussion.Thirteen papers were critically appraised [40–52]. Theprocess of searching, selecting and assessing papers forinclusion is documented in Figure 1.

Data extraction

Data from the included eight papers were extractedby TLN and organized in extraction templates,adapted from the JBI-MAStARI data extraction tool[37]. The templates contained author, year of publica-tion, type of trial, method, setting, participants andinterventions in each group. Descriptive statistics(in-group and between-groups results at baseline, postintervention and at follow-up) were extracted as werealso test results (tests and p-values). A statistician was

Table 2. Inclusion and exclusion criteria.Characteristics of the papers Inclusion: Quantitative or mixed methods scientific studies addressing effectiveness. Experimental study designs

(randomized/non-randomized controlled trials and quasi-experimental studies). Original studies, published inpeer-reviewed scientific journals. No time restrictions. Written in English, German, Danish, Norwegian orSwedish

Exclusion: Systematic reviews and meta-analyses, pilot/preliminary and feasibility studies. Studies with a primaryhealth economic perspective

Population Inclusion: Home-dwelling, age 60þ, reduced level of functioning due to health problemsExclusion: Studies specifically about OT for older adults with dementia or cancer at a terminal stage

Interventions Inclusion: Occupation-focused and occupation-based occupational therapy where occupational performance wasassessed before and after the intervention, where the aim was to improve occupational performance, andwhere activities and tasks were practiced as a major part of the intervention. Occupational therapists per-formed the major parts of the planning and the executionExclusion: Main focus on falls prevention, on prevention of functional decline in older adults without functionalproblems, on driving a car, or on the provision of assistive devices and home adaptations without explicit prac-tice of occupational performance. Group-based interventions. Pre-discharge home visits or interventions takingplace both at a hospital and in the home

Comparators Inclusion: Other occupational therapy interventions, usual practice or no interventionOutcomes Inclusion: Quantitatively measured between-group differences in occupational performance assessed with validated

toolsContext Inclusion: The usual contexts of the participants’ occupational performance: primarily the home, but also other

natural or built environments, a garden, a shop, a city bus, etcExclusion: Institutional setting (hospital, rehab centre, etc.)


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consulted to ensure the correct understanding andreporting of the results.

Data analysis and synthesis

For this review, effectiveness of OT was defined asstatistically significant between-group differences in

occupational performance, in favor of an interven-tion group. Short-term effectiveness was defined aseffectiveness reported post intervention, i.e. at thetime of discharge from the home-based OT. Long-term effectiveness was defined as effectiveness meas-ured at least six months after discharge from thehome-based OT. The assessments and interventions

Figure 1. Flow diagramme detailing results of literature search, study selection and assessment of methodological quality.


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were labeled occupation-focused and/or occupation-based or partly so, following the definitions in Table1. The results concerning occupational performancewere categorized according to the focus of theassessment tools used in the studies, namely ADL,IADL, leisure, or occupational performance and sat-isfaction. Results were restricted to one (primary)assessment tool per category, as indicated in thepapers. p-Values below 0.05 were considered statis-tically significant. Meta-analyses were not performedfor the following statistical and clinical reasons:Statistically, the results were not always reported insufficient detail and could in most cases not becombined. Clinically, heterogeneity was present con-cerning health problems, length of interventions, andoutcomes measured. Instead of meta-analyses, theresults were summarized in words, supplemented bytables [37,53].

Results

Eight papers, reporting six studies, were finallyincluded [40–47]; the results of the appraisals are pre-sented in Table 3.

The included studies met 80–90% of the criteria onthe JBI-MAStARI checklist. No study met the criter-ion about participants’ blinding to treatment alloca-tion, and only one study fully met the criterion aboutan intention-to-treat analysis [43].

Description of the included studies, studypopulations, and contexts

The included studies were European [40–43,46,47] orNorth American [44,45] randomized, controlled trials,published in English between 1999 and 2015. From163 to 374 participants were included in the analyses.Tables 4, 5 and 6 present the main characteristics ofthe studies, related to diagnostic groups: stroke (Table4) [40–43]; Parkinson’s disease (Table 5) [46]; or mul-tiple, chronic health problems (Table 6) [44,45,47].

The mean age spanned from 71 to 80 years, the pro-portion of females from 38 to 82%. In studies amongolder adults with stroke or Parkinson’s disease, themean age and the proportion of females was lowerthan in studies among older adults with multiple,chronic health problems. The older adults lived in pri-vate homes in the community, except in one study inwhich eight of the participants (4.7%) lived in a carehome [43].

Occupation-focused assessments

The terms occupation-focused and occupation-basedwere not used in any paper; yet, an analysis of thepapers shows that occupation-focused assessmenttools were used in all studies. Questionnaires withpredetermined activities and tasks were used to assessADL, IADL and leisure. ADL was assessed on theBarthel Index [40–42], the ADL Index [44,45] and theBasic ADL scale (b-ADL) [47]. IADL was assessed onthe Extended ADL scale (EADL) [40,41], theNottingham Extended ADL-scale (NEADL) [42] orthe IADL index [44,45]. Leisure was assessed on theNottingham Leisure Questionnaire (NLQ) [42,43].More client-centred assessments included a singlequestion on whether the person got out of the houseas often as wanted [43], and the assessment of client-identified occupational performance issues (occupa-tional performance and satisfaction) on the CanadianOccupational Performance Measure (COPM) [46].The assessment tools are shown for each study inTables 4, 5 and 6. No occupation-based assessments(observational tools) were used. In all studies, theassessments of occupational performance were supple-mented by other assessments, e.g. assessments ofhandicap, general health, physical and mental bodyfunctions, environmental hazards, satisfaction withinterventions, quality of life and careers’ outcomes.The results of these supplemental assessments are notreported in this review.

Table 3. Appraisal of the included papers by the JBI-MAStARI critical appraisal checklist.1 2 3 4 5 6 7 8 9 10 POINTS

Walker et al. [40] Y N Y N Y Y Y Y Y Y 8/10Walker et al. [41] Y N Y N Y Y Y Y Y Y 8/10Parker et al. [42] Y N Y N Y Y Y Y Y Y 8/10Logan et al. [43] Y N Y Y Y Y Y Y Y Y 9/10Gitlin et al. [44] Y N Y N Y Y Y Y Y Y 8/10Gitlin et al. [45] Y N Y N Y Y Y Y Y Y 8/10Sturkenboom et al. [46] Y N Y N Y Y Y Y Y Y 8/10De Vriendt et al. [47] Y N Y N Y Y Y Y Y Y 8/10

1–10¼ The questions from the MAStARI tool for RCTs: 1. Was the assignment to treatment groups truly random? 2. Were the participants blinded totreatment allocation? 3. Was the allocation to treatment groups concealed from the allocator? 4. Were the outcomes of people who withdrew describedand included in the analysis? 5. Were those assessing outcomes blind to the treatment allocation? 6. Were the control and treatment groups comparableat entry? 7. Were groups treated identically other than for the named interventions? 8. Were outcomes measured in the same way for all groups? 9.Were outcomes measured in a reliable way? 10. Was appropriate statistical analysis used? Y: Yes, N: No. U: Unclear.


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Table 4. The effect of home-based occupational therapy on occupational performance of older adults with stroke.

Study/country/purpose Design Participants Intervention/controlOutcomes: assessmenta/

Resultsb

Walker et al. (1999þ 2001)UKTo study the effect of OT on

ADL and IADL,compared with no interven-

tion for older adults withstroke who were notadmitted to hospital

RCT2 groupsN¼ 163 at six mthsN¼ 147 at 12 mths

Mean age 74 yrs.Females 49%Lived alone 33%Ethnicity –Health: Stroke within onemonth

Group A: occupation-focused,occupation-based OT

Occupation-focused aim:Independence in ADLand IADL

Occupation-based interven-tion: Active interventionin ADL and IADL. Specifictasks were set as home-work when possible

Individual relevance ofpracticed activities or goalsetting not mentionedTime: Up to five mths,mean 5.8 sessions

Group B: ControlRoutine practice, existing

services

ADL (Barthel Index):Short-term six mths: OT group

benefited the most, diff.btw. groups 1 (95% CI 0;1),Mann–Whitney, p¼ .002

Long-term 12 mths: Nodifference

IADL (EADL):Short-term six mths: OT group

benefited the most, diff.btw. groups 3 (95% CI 1;4)Mann–Whitney, p¼ .009

Long-term 12 mths: OT groupbenefited the most,Mann–Whitney, p¼ .04

Parker et al. (2001)UKTo evaluate effects of leisure

therapy and conventionalOT on mood, leisure andindependence in ADL afterstroke

RCTthree groupsN¼ 374 at six mthsN¼ 331 at 12 mths

Mean age 72 yrsFemales 42%Lived alone 32%Ethnicity –Health: Stroke, withinsix mths from hospitaldischarge

Group A: partly occupation-focused, occupation-basedOT

Partly occupation-focused aim:Improvement in leisureperformance and mood

Occupation-based interven-tion: Leisure taskspracticedþADL tasksnecessary to achieve leisureobjectives

Goal-setting for leisure activityTime: Up to six mths, mean

8.5 sessionsGroup B: partly occupation-

focused, occupation-basedOT

Partly occupation-focused aim:Improvement in self-careand mood

Occupation-based interven-tion: Self-care tasks werepracticed

Goal-setting for self-care tasksTime: Up to six mths, mean

8.5 sessionsGroup C: Control. No therapyAll participants could receive

other existing services

ADL (Barthel Index)Short-term six mths:

No differencesLong-term 12 mths:

No differencesIADL (NEADL)Short-term six mths:


No differencesLeisure (NLQ)Short-term six mths:


No differences

Logan et al. (2004)UKTo evaluate an OT interven-

tion to improve outdoormobility after stroke

RCT2 groupsN¼ 168 at four mthsN¼ 168 at 10 mths

Mean age 74 yrsFemales 46%Lived alone 40%Ethnicity –Health: Stroke within 36 mths(mean 10–11 mths)

Group A: occupation-focused,partly occupation-based OT

Occupation-focused aim:Independence in outdoormobility

Occupation-based interven-tion: Assessment of barriers,information, minor aids oradaptations, mobility waspracticed

Goal-setting for mobilityTime: Up to three mths,mean 4.7 sessions

Group B: Control. Routine OT.See below

All participants received onestandard session: advice,encouragement, leaflets onlocal mobility services

IADL (Got out of house aswanted)

Short-term four mths: OTgroup benefited the most,RR 1.72 (95% CI 1.25; 2.37),p< .001

Long-term 10 mths: OT groupbenefited the most,Relative risk 1.74 (95% CI1.24; 2.44), p¼ .001

Leisure (NLQ)Short-term four mths:


No differences

OT: occupational therapy; ADL: Activities of Daily Living; IADL: Instrumental Activities of Daily Living; RCT: Randomized controlled trial; N: Number analysed;mths: Months; yrs: Years; CI: Confidence interval; EADL: Extended Activities of Daily Living Scale; NEADL: Nottingham Extended Activities of Daily LivingScale; NLQ: Nottingham leisure questionnaire.aOnly assessments of occupational performance are reported.bOnly statistically significant results are reported in detail.


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Occupation-focused and occupation-basedinterventions

An analysis of the papers shows that all the describedOT interventions were occupation-focused or partlyoccupation-focused; the latter applies when the pri-mary aims did not include only occupational perform-ance, but also body functions and environmentalfactors. The interventions were also deemed occupa-tion-based or partly occupation-based. The latterapplies when the practicing of activities and tasksthrough acquisitional or adaptive models was supple-mented with practice at body level or by education ofcaregivers, for example. The interventions of eachstudy are shown in Tables 4, 5 and 6. While the inter-ventions were only sparsely described in the earliestpapers [40,42], the four most recent papers explainedthe use of acquisitional and adaptive occupationthrough various combinations of cognitive, behavioraland environmental strategies to improve occupationalperformance and safety [43–47]. One multicomponenthome intervention supplemented OT with one sessionon balance, muscle strengthening and fall-recoverytechniques with a physiotherapist [44]. Goal setting ormeeting participants’ priorities were highlighted infive studies [42–44,46,47]. The interventions weredelivered over 2.5–6 months. The mean number of

OT sessions varied between studies from 1.9 to 8.6;the mean intensity varied from 0.8 to 3.4 sessions permonth of intervention. A reinforcement strategy withfollow-up phone calls between the 6th and the 12thmonth and a final home visit was implemented in theGitlin study [44]. In four studies, all participantswere eligible for routine community services.[40,42,46,47]. In one study, a routine OT session wasoffered to the control group [43]; in another study, noservice or intervention was offered to the controlgroup [44].

Short and long-term effectiveness ofoccupation-focused and occupation-basedinterventions

The studies show that OT in the homes of olderadults can effectively improve older adults’ occupa-tional performance at short term and to some degreeat long term, even if the included papers are notunanimous in their conclusions. As the target groupsvaried between studies, the results are grouped as fol-lows: OT for older adults with stroke (Table 4), OTfor older adults with Parkinson’s disease (Table 5)and OT for older adults with multiple, chronic healthproblems (Table 6).

Table 5. The effect of occupational therapy on occupational performance of older adults with Parkinson’s disease.


resultsb

Sturkenboom et al. (2014)The NetherlandsTo examine the efficacy of OT

according to Dutch practiceguidelines for people withParkinson’s disease

RCT multicentretwo groupsN¼ 185 atthree mthsN¼ 181 atsix mths

Mean age 71 yrsFemales 38%Lived alone–Ethnicity–Health: Parkinson’s disease

with difficulty in meaning-ful daily activities, no pre-dominant disablingcomorbidity

Group A: occupation-focused,partly occupation-based OT

Occupation-focused aim:Improvement in activities

Partly occupation-based inter-vention: Advice, strategytraining in activities, adap-tations of tasks, daily rou-tines or environment. Thecaregivers’ needs in sup-porting the older adultwere addressed if needed.The mix of interventionstrategies was individuallytailored.

Goal-setting for activities pri-oritized by the older adult

Time: 10 weeks, mean 8.6 ses-sions

Group B: ControlUsual care. No OTAll participants and their care-

givers could receive othermedical, psychosocial, orallied health-careinterventions

Occupational performance(COPM):

Short-term three mths: OTgroup benefited the most

Diff. btw. groups 1.2 (95% CI0.8; 1.6)

Linear regression, p< .001Short-term six mths: OT group

benefited the mostDiff. btw. groups 0.9 (95% CI

0.5;1.3)Linear regression, p< .001Satisfaction with performance

(COPM):Short-term three mths: OT

group benefited the mostDiff. btw. groups 1.1 (95% CI

0.7; 1.5)Linear regression, p< .001Short-term six mths: OT group


0.5; 1.3).Linear regression, p< .001

OT: Occupational therapy; RCT: Randomized controlled trial; N: Number analysed; mths: Months; yrs: Years; COPM: Canadian occupational performance meas-ure; CI: Confidence interval.aOnly assessments of occupational performance is reported.bOnly statistically significant results are reported in detail.


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Table 6. The effect of occupational therapy on occupational performance of older adults with multiple, chronic health problems.


resultsb

Gitlin et al. (2006þ 2008)USATo test the efficacy of an OT

intervention to reducefunctional difficulties, fearof falling and homehazards; and to enhanceself-efficacy and adaptivecoping

Subgroup analyses exploredwhether some groupsbenefitted more thanothers

RCT2 groupsN¼ 300 atsix mthsN¼ 285 at12 mths

Mean age 79 yrsFemales 82%Lived alone 62%Ethnicity:43% white46% African AmericanHealth: Chronic health prob-

lems, with need for help ordifficulties with ADL orIADL, but not receivinghome care

Group A: Partly occupation-focused, partly occupation-based OT

Partly occupation-focused aim:to reduce functionaldifficulties, fear of fallingand home hazards; and toenhance self-efficacy andadaptive coping

Partly occupation–basedintervention: the use ofcognitive, behavioral andenvironmental strategieswere practiced throughoccupation: problem solv-ing, energy conservation,safe performance and fallrecovery. Home modifica-tions and training in theiruse. Physio therapy:balance and musclestrength training

Goal setting not specificallymentioned, but the inter-ventions focused exclusivelyon the areas reported asproblematic by the olderadults

Time: six mths, mean 5 OTsessions of which one wasa telephone contact. 1physiotherapy session.

Reinforcement btw. 6 and 12mths: 3 phone callsþ finalhome visit by an occupa-tional therapist

Group B: ControlNo intervention until the end

of the study

ADL (ADL Index):Short-term six mths: OT group

benefited the mostDiff. btw. groups �0.13 (no

CI),ANCOVA p¼ .03>80-year-olds, women and

educated below highschool benefited the mostat six mths

Long-term 12 mths:No difference

>80-year-olds benefited themost at 12 mths

IADL (IADL Index):Short-term six mths: OT group

benefited the mostDiff. btw. groups �0.14 (no

CI), ANCOVA p¼ .04Long-term 12 mths: No differ-

enceWhites benefited the most at

12 mths

De Vriendt et al. (2015)BelgiumTo examine the effectiveness

of a client-centred andactivity oriented interven-tion with the main focuson basic ADL

RCT2 groupsN¼ 168 at10 weeks

Mean age 80 yrsFemales 80%Lived alone 100%Ethnicity –Health: Frail older adults with

chronic health problems.One or more functionalproblems in ADL. Receivinghealth care support

Group A: Occupation-focusedand partly occupation-based OT

Occupation-focused aim:improvement in basic ADL.

Partly occupation-based inter-vention: a client-centred,tailored to the needs of theperson and activity ori-ented program. Training offunctional skills, advice andinstruction in use of assist-ive devices, education ofcaregiver

Goal setting: client-centredgoals and negotiation oftherapy plan

Time: 10 weeks, mean 1.9sessions

Group B: Control. Usual care.See below

All participants could receiveusual health care/commu-nity care services: supportin housekeeping and self-care, nursing support andsocial follow-up support

ADL (b-ADL scale):Short-term 2.5 mths: OT group


1.4; 12.1).ANCOVA p¼ .001

OT: Occupational therapy; ADL: Activities of Daily Living; IADL: Instrumental Activities of Daily Living; RCT: Randomized controlled trial; N: Number ana-lysed; mths: Months; yrs: Years; b-ADL: Basic activities of daily living-scale; CI: Confidence interval.aOnly assessments of occupational performance is reported.bOnly statistically significant results are reported in detail.


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OT for older adults with stroke

Three studies (Table 4) targeted older adults withstroke [40–43].

In the randomized controlled trial (RCT) byWalker et al. [40,41], five months of occupation-focused and occupation-based OT was performedwith non-hospitalized older adults post stroke andcompared with routine practice. The OT interventionwas not reported in much detail. Significant between-group differences in Barthel Index scores postintervention suggest a short-term effect on ADL per-formance. Nevertheless, this effect was not maintainedat the 12-month follow-up (long term). Significantbetween-group differences in EADL scores post inter-vention and at the 12-month follow-up suggest bothshort-term and long-term effects on IADLperformance.

In the RCT by Parker et al. [42], six months ofpartly occupation-focused and occupation-based OTwas performed with older adults post stroke and com-pared with no intervention. Two intervention groupsreceived OT which emphasized either leisure or ADLperformance. A control group received no therapy.The OT interventions were not reported in muchdetail. No significant differences in Barthel Indexscores, NEADL scores, or NLQ scores were detected,neither post intervention, nor at the 12-month follow-up. In both intervention groups, small but insignifi-cant improvements in the NEADL scores weredetected; and in the leisure group, a small but insig-nificant improvement in leisure was detected. In con-clusion, no major beneficial short-term or long-termeffects on ADL, IADL, or leisure were reported.

In the RCT by Logan et al. [43], three months ofoccupation-focused and occupation-based OT wasperformed with older adults post stroke and com-pared with one session of routine OT. The strategiesused in the OT intervention were described in detail.Highly significant differences in the participants’ per-ceptions of whether they got out of the house as oftenas they wanted post intervention and at the 10-monthfollow-up suggest both short-term and long-termeffects on outdoor mobility. No significant short-termor long-term differences in leisure performance weredetected.

OT for older adults with Parkinson’s disease

One study, included in Table 5, targeted older adultswith Parkinson’s disease [46]. Occupational perform-ance and satisfaction were the assessed outcomes. Inthis RCT by Sturkenboom et al. [46], 10 weeks of

occupation-focused and partly occupation-based OTfor older adults with Parkinson’s disease was per-formed and compared with usual care. The strategiesused in the OT intervention were described in detail.Highly significant between-group differences inCOPM performance scores and in COPM satisfactionscores post intervention and at the six-month follow-up suggest a short-term effect on occupational per-formance and satisfaction. No long-term follow-upwas performed, but the achieved effects were main-tained three months post intervention.

OT for older adults with multiple, chronic healthproblems

Two studies, included in Table 6, targeted older adultswith multiple, chronic health problems [44–47].

In the RCT by Gitlin et al. [44], six months of partlyoccupation-focused and occupation-based OT was per-formed with older adults with chronic health problemsand compared with no intervention. The strategiesused in the OT intervention were described in detail.The presence of small but significant differences on theADL Index post intervention suggests a short-termeffect on ADL performance. However, this effect wasnot maintained at the 12 months follow-up. Post-hocanalyses on subgroups showed that above 80-year-olds,women, and those educated below high school levelbenefited the most on ADL at 6 months; above 80-year-olds benefited the most at 12 months [45]. Smallbut significant differences were also reported on theIADL Index post intervention, suggesting a short-termeffect on IADL performance. However, this effect wasnot maintained at the 12-month follow-up. Post-hocanalyses of subgroups showed no sub-group differencesconcerning IADL at six months; at 12 months, whitesbenefited the most [45].

In the RCT by de Vriendt et al. [47], 10 weeks ofoccupation-focused and partly occupation-based OTwas performed with frail older adults with multiple,chronic health problems and compared with usualcare. The strategies used in the OT intervention weredescribed in detail. Significant differences in b-ADLscores suggest a short-term effect on ADL perform-ance. No long-term follow-up was performed.

Discussion

Previous reviews offer evidence that general modelsand strategies for OT delivered both in homes, as out-patient therapy, and in hospitals have an effect onhome-dwelling older adults’ ADL and IADL perform-ance [27–36]. Pursuant to the aim of the present


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review, viz. to strengthen evidence-based OT practice,we focused on the short-term and long-term effective-ness of specifically occupation-focused and occupa-tion-based OT delivered only in and around thehomes. Positive results are reported across all targeteddiagnostic groups (older adults with stroke, olderadults with Parkinson’s disease and older adults withmultiple, chronic health problems) as well as amongolder adults at increased risk of disability. Short-termeffectiveness of the OT interventions are seen in all thediagnostic groups on ADL, IADL and client-identifiedoccupational performance issues [40,43,44,46,47]. OTinterventions that are largely occupation-focused andoccupation-based can, seemingly, be adapted toaddress the special needs related to neurologic diseaseswith an acute onset (stroke) and with a slow develop-ment (Parkinson’s disease), as well as the needs relatedto gradually developing multiple chronic health prob-lems, regardless of whether the older adults wererecently discharged from hospital or not.

Long-term effectiveness of the OT interventions onIADL performance are seen in two studies amongolder adults with stroke (Walker, Logan) but not inthe study among older adults with multiple chronichealth problems (Gitlin). In none of the studies, along-term effect was found on ADL [41–43]. The dif-ferences in long-term effectiveness between theincluded diagnostic groups on IADL and the lack oflong-term effectiveness on ADL may to some extentbe due to the nature of the older adults’ health prob-lems. Different recovery-patterns after an acute strokeepisode and after a gradually diminished level of func-tioning due to various health problems, may accountfor the differences in outcomes. In addition, the par-ticipants who had multiple chronic health problemswere older and generally frailer than the participantswith stroke. Longitudinal studies show that frail olderadults who have undergone rehabilitation maydevelop recurrent disability over the following sixmonths due to fluctuations or more permanent deteri-orations in their health [54,55]. The need for pro-grammes to retain independence in older adults haspreviously been raised [54,56], and studies haveshown that reinforcement strategies after rehabilita-tion can improve treatment compliance, self-efficacyand perceptions of being informed [57,58]. In onestudy included in the present review, phone calls anda follow-up visit were used to reinforce and generalizethe use of strategies, seemingly without influencingthe long-term results [44]. More research is neededon how older adults can maintain improvementsachieved through OT. Such research may explore, for

instance, whether occupation-based face-to-faceencounters at follow-up visits where client-identifiedproblems with tasks and activities are reevaluated andpracticed can more effectively help maintain theresults of OT in the long term. Such research mayexpediently be performed in a reablement home-carepractice [28,59]. Previous research has called for eval-uations regarding the most effective duration, timingand intensity of restorative interventions for olderadults [28]. In qualitative studies, older adults havereported that discharge from home-based OT cametoo soon; they felt that with more time they couldhave gained more [16,17]. The amount of OTreported in the present review was low, from as littleas a mean of 1.9 to 8.6 sessions; and OT was deliveredover 2.5 to 6 months. This low intensity may havehad a negative bearing on the effectiveness of the OTintervention. For some older adults, it may take morethan just a few sessions to learn, integrate and con-solidate new strategies in everyday life [60]. In areview about the effect of OT on self-care outcomes,several studies showed that a greater intensity of OTalone or as part of a multidisciplinary interventionsignificantly improved functional outcomes amongolder adults in nursing homes and among strokepatients [61]. Future studies may explore whetherinterventions of 12 or more sessions, delivered morefrequently, e.g. twice weekly, may more effectivelyhelp home-dwelling older adults to improve andmaintain their occupational performance.

The effect sizes were small in some of the studies ofthe present review, even though they were statisticallysignificant. As an example, the between-group differen-ces did not reach the established minimal clinicallyimportant differences on the Barthel Index [40–42,62]and on the COPM [46,63]. Previous research hasshown that older adults often perform ADL near theirmaximal capabilities [64]; and even small, negativechanges can result in disability. In the light of theseresults, it has been suggested that even modestimprovements can be of much importance to the indi-vidual older adult’s life [45]. Future studies of minimalclinically important differences in populations of olderadults and qualitative exploration of older adults’ per-ceptions of the outcomes of home-based OT may addnew perspectives on how to evaluate the effectivenessof rehabilitation for this heterogeneous client group.

The importance of choosing sensitive assessmenttools for OT practice and research validated in rele-vant study populations has been stressed [60,65]. Inthe present review, lack of proved effectiveness onsome outcomes may be due to clinimetric issues.


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Thus, in a number of studies, the Barthel Index hasbeen deemed insensitive at extremes of ability, lessdiscriminating in patients with minor stroke eventsand not sufficiently sensitive for long-term assess-ment [62]. In the Walker and the Parker studies ofthe review, these three problems were all present[40–42], and the between-group differences in ADLoutcome of the older adults with stroke may conse-quently have been underestimated [40–42]. Anotherimportant issue is what is actually assessed by thetools used to evaluate the OT interventions in thestudies of the present review. When performing andtesting occupation-focused, occupation-based and cli-ent-centred OT, we encourage the use of assessmenttools that include client-identified performanceissues or goals [19,20,66]. Examples of validated,occupation-focused and occupation-based tools thatreflect the clients’ individual priorities and problemsare the COPM, The ADL taxonomy, TheAssessment of Motor and Process Skills and TheOccupational Self Assessment [67–70]. It is notice-able that even though most of the papers in thepresent review emphasized listening to the olderadults’ individual wishes and goals [42–47], themajority of assessment tools did not necessarilyreflect the participants’ own priorities since theymeasured performance of predetermined activitiesand tasks [40–45,47]. Improvements in performanceof client-identified and valued occupations may thushave gone undetected in some of the reviewed stud-ies. Assessments that reflect the older adults’ occu-pational performance issues and goals should beincluded by occupational therapists and researcherswhen client-centred OT is performed and tested.

Strengths and limitations

A strength at study level of the present review wasthat all the included studies were RCTs at evidencelevel 1c according to the Joanna Briggs Institute[71], and they all met minimum eight of ten criteriaon the JBI-MAStARI checklist. One limitation wasthat blinding of participants was not performed inany of the studies. However, this problem may beseen as an inevitable premise for behaviorally basedinterventions commanding the client’s active partici-pation [72]. Another limitation was that in five stud-ies, full intention-to-treat analyzes with imputationsof missing values were not performed; this mighthave led to a biased estimation of treatment effect[53]. In the two studies with larger losses to follow-up (21 and 29% at 12 months) [41,42], the risk ofnon-response bias was seen as modest by the

authors. They emphasized that the losses were ofsimilar size in the randomized groups [41,42], mostof the losses were due to death not linked to thestudy [41], and non-responders did not differ fromresponders at baseline [42]. In sum, the includedstudies are considered to be of high methodologicalquality with modest risk of bias.

A strength at review level was the systematic andcritical approach adopted throughout the review pro-cess. The librarian-assisted, systematic literature searchin seven databases was comprehensive, and eight stud-ies were finally included. The concepts of occupation-focused and occupation-based OT were used in thereview, building on Fisher’s theoretical work [19,20].Fisher’s concepts were not introduced at the publica-tion time of the earliest studies of the review andwere not used to describe the interventions of any ofthe included studies. Yet, analyses support the validityof the concept since the interventions of the includedstudies could be deemed occupation-focused andoccupation-based. This strengthens the conceptualfoundation of the findings. A limitation was that onlystudies among older adults with physical health prob-lems (stroke, Parkinson’s disease and multiple chronichealth problems) were identified. There may not begeneralizability of the results to people with otherphysical health problems. In addition, no suggestionscan be made concerning the effectiveness of occupa-tion-focused and occupation-based OT among olderadults with mainly mental health problems since wedid not find any studies within this field suitable forinclusion. The summaries cannot provide pooled stat-istical evidence such as a meta-analysis. Nevertheless,collectively the systematic and critical approachthroughout the review and the summaries allow us toidentify best current evidence of effectiveness as wellas advice and new directions for practice andresearch.

Table 7. Implications for practice and research.� Occupation-focused and occupation-based OT in the home with the

application of cognitive, behavioral and environmental strategies canimprove the performance of ADL, IADL and client-identified occupa-tions of older adults with physical health problems

� Maintenance programs for older adults after discharge from home-based OT should be developed and tested by occupational therapistsand researchers, aiming to improve long-term effectiveness

� Intensive OT programs for older adults at home, e.g. twice a weekwith minimum 12 sessions in total, should be developed and testedby occupational therapists and researchers, aiming to improveeffectiveness

� Assessments that reflect the older adults’ occupational performanceissues and goals should be included by occupational therapists andresearchers when client-centred OT is performed and tested

� Future studies of older adults’ perceptions of the outcomes of home-based OT may add new perspectives on how to evaluate the effect-iveness of rehabilitation for this client group


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Conclusion and implications for practice andresearch

In conclusion, despite the limited number of includedstudies, this review indicates that occupation-focusedand occupation-based OT of lower intensity, whereactivities and tasks are practiced as a major part ofthe intervention, and cognitive, behavioral and envir-onmental strategies are used, can significantly improveADL, IADL and client-identified occupational issuesin older adults with physical health problems at shortterm. Positive long-term effects were found on IADL,but difficulties prevail concerning long-term mainten-ance of improvements, especially within ADL. Someeffects were of modest size, yet they may still be ofindividual value to the participants. The implicationsfor practice and research are summarized in Table 7.

Disclosure statement

The authors report no conflicts of interest. The authorsalone are responsible for the content and writing of thisarticle.

Funding

This work was supported by The Danish Association ofOccupational Therapists [grant number FF 2 13-11].

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Appendix 1. Initial keywords and an example of a search string.Cochrane (MeSH and free text): occupational therapy, activities of daily living, self-care, independent living, home, residence characteristicsPubMed (MeSH and free text): occupational therapy, goal setting, ADL-based, activities of daily living, home, residence characteristics, independent living,community dwellingEmbase (Emtree and free text): occupational therapy, occupational therapist, home rehabilitation, activities of daily living, home, community livingCinahl (Cinahl headings and free text): occupational therapy, home occupational therapy, adl-based, activities of daily living, residence characteristics,home, community dwellingPsych INFO (SU exact and free text): occupational therapy, home rehabilitation, occupation-based, activities of daily living, daily activities, social participa-tion, home, home basedSweMed1 (MeSH and free text): occupational therapy, homeOT-seeker (free text): occupational therapy, occupational, occupation based, goal setting, ADL-based, ADL, home, community dwelling

PubMed Search, Query, Items found#5, ‘Search (((((occupational therapy[MeSH Terms]) OR “occupational therapy”) OR “ADL-based”)) AND activities of daily living[MeSH Terms]) AND((((home) OR residence characteristics [MeSH Terms]) OR independent living [MeSH Terms]) OR “community dwelling”) Filters: Aged: 65þ years’, 327#4, ‘Search (((((occupational therapy[MeSH Terms]) OR “occupational therapy”) OR “ADL-based”)) AND activities of daily living[MeSH Terms]) AND((((home) OR residence characteristics[MeSH Terms]) OR independent living [MeSH Terms]) OR “community dwelling”)’, 492#3, ‘Search (((home) OR residence characteristics[MeSH Terms]) OR independent living[MeSH Terms]) OR “community dwelling”’, 247671#2, ‘Search activities of daily living[MeSH Terms]’, 54798#1, ‘Search ((occupational therapy[MeSH Terms]) OR “occupational therapy”) OR “ADL-based”’, 19769


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Appendix 3

Article 3

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British Journal of Occupational Therapy

Article in press January 2018. DOI 10.1177/0308022618756217

Older adults’ experiences and expectations after discharge from

home-based occupational therapy

Tove Lise Nielsen1,2,3, Merete Bjerrum4, Claus Vinther Nielsen2,3, Kirsten Schultz

Petersen5,3

1VIA University College, Department of Occupational Therapy, Aarhus Denmark 2Aarhus University, Department of Public Health, Section for Clinical Social Medicine and Rehabilitation, Aarhus, Denmark 3DEFACTUM Central Denmark Region, Aarhus, Denmark 4Aarhus University, Department of Public Health, Section for Nursing Science, Aarhus, Denmark 5Aalborg University, Department of Health science and Technology, The Faculty of Medicine, Public Health and Epidemiology Group, Denmark

Abstract

Introduction: Home-based occupational therapy can improve older adults’ occupational performance, but maintaining improvements presents challenges, and service development is needed. In this study, older adults’ experiences and expectations concerning their occupational performance after discharge from home-based occupational therapy were examined and used to develop suggestions for improved practice.

Method: Semi-structured qualitative interviews were conducted with eleven older adults living alone or with a spouse. The interviews were analysed using inductive qualitative content analysis.

Findings: The older adults still strove to improve and maintain their occupational performance using various strategies; their desire for independence was strong, but some could accept a lesser degree of independence.

Conclusion: From the findings and existing literature, ideas were developed to improve home-based occupational therapy and support maintenance of occupational performance after discharge. These ideas include 1) finding strategies to achieve satisfactory occupational performance that does not necessarily entail full independence 2) increased focus on the use

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and transfer of problem-solving strategies 3) acknowledging and addressing possible reluctance to use assistive devices, and 4) individually scheduled follow-up visits post OT. Future research should examine effectiveness and applicability of these ideas.

Keywords

Content analysis, elderly, home, occupational performance, occupational therapy, older adults

Introduction

This qualitative study explores older adults’ experiences of their occupational performance in everyday life post discharge from home-based occupational therapy (post OT). Occupational performance, the primary focus of occupational therapy (OT), is defined by Townsend and Polatajko (2013) as ‘the ability to choose, organize, and satisfactorily perform meaningful occupations that are culturally defined and age appropriate for looking after oneself, enjoying life and contributing to the social and economic fabric of a community’. Many older adults with chronic health issues experience declining occupational performance, and since the proportion of adults aged 65+ is growing rapidly, there is societal interest in restoring and maintaining their independence and wellbeing (Christensen et al., 2009). In Denmark, 72% of registered occupational therapists work in the municipalities, where the majority of their clients are older adults in need of rehabilitation (Ergoterapeutforeningen, 2015). OT often takes place in older adults’ homes, to ensure transfer to everyday life (Fisher, 2009). While evidence shows that older adults’ occupational performance can improve through home-based OT, the improvements are not always maintained in the longer term (Nielsen et al., 2017). It is not clear why some older adults have problems maintaining the achieved improvements, while others succeed to a greater degree. Problems may be due to deteriorating or fluctuating health (Fried and Guralnik, 1997), changes to the older adults’ everyday lives or environments post OT, or factors directly related to OT processes and outcomes.

Literature review

The Person-Environment-Occupation (PEO) model (Law et al., 1996) explains occupational performance as an interaction among the PEO components and occupational performance problems as the result of a misfit between two or more PEO components (Law et al., 1996; Townsend and Polatajko, 2013). Rehabilitative measures to improve older adults’ occupational performance address one or more PEO components.

Previous studies, mainly from Western Europe, North America and the Middle East, show that occupation-based OT for older adults, delivered in the home and other contexts, has a potential to improve occupational performance in the short term, but the long-term maintenance of achieved effects presents challenges as the improvements tend to diminish at follow-up (Nielsen et al., 2017, 2018, Steultjens et al., 2004). The same pattern is found in studies of multi-disciplinary interventions (Fleischmann et al., 2012; Hershkovitz et al., 2012, Tuntland et al., 2015). Participants have reported being unprepared for discharge from OT and feeling that they could have achieved more, had they been given a greater number of sessions

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(Boutin-Lester and Gibson, 2002). Older adults, living alone or with a spouse, have reported strategies for maintaining and improving occupational performance including planning and continuing important activities, maintaining bodily functions, receiving help from spouses, family or others, maintaining social networks, and moving into accessible housing (Bergström et al., 2015; Vik and Eide, 2014; Yuen et al., 2007). To our knowledge, no qualitative studies have examined specifically how older adults with various chronic health issues experience and maintain their occupational performance post home-based OT. The aim of this qualitative study was to extend current understandings of older adults’ experiences and expectations concerning their occupational performance post home-based OT, as this may inspire occupational therapists to plan and perform home-based interventions aiming for greater long-term effectiveness.

Two primary research questions were posed:

1. How do older adults who have had home-based OT experience their occupational performance post OT?

2. What do older adults who have had home-based OT expect concerning their occupational performance in the future?

Method

Setting and intervention The study took place in a Danish municipal home-care context, where older adults commonly live alone or with a spouse. OT is delivered by registered occupational therapists to people with declining occupational performance due to illness, disabilities, injuries or more general aging processes, with the aim to improve independence and quality of life. The study participants had received OT in their homes and local environments, where occupation-based interventions had engaged them in real-life activities for at least three weeks; assistive devices and minor home adaptations had been introduced free of charge, when necessary. Discharge had taken place 2-11 weeks before the interview.

Sampling The inclusion criteria (Table 1) ensured that the sample mirrored the diversity among older adults typically referred to Danish home-based and occupation-based OT.

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Table 1. Inclusion and exclusion criteria. Inclusion Age: 65+ Housing: Private homes or sheltered (senior) housing Health: Experienced chronic health issues Occupational performance: At the time of referral to OT, the participant experienced problems that hampered his/her independence in everyday life Language: Danish speaking and able to tell about their everyday lives in relation to home-based OT Home-based OT: discharged 2 to 12 weeks ago Exclusion Health: Alcohol or drug abuse, tetraplegia, dementia, or severe intellectual disability, rapidly progressive diseases such as cancer or motor neuron disease.

Purposeful sampling (Crabtree and Miller, 1999) aimed for maximum variation concerning gender, age, need for assistance, living arrangement, and referral route. Information concerning the study’s aim, inclusion criteria and procedures was given to managers of OT services in 19 municipalities chosen to broadly represent the country’s regions as well as rural and urban areas. The managers invited clients who matched the inclusion criteria. After inclusion of five participants, we decided which characteristics, typical for the Danish population, were missing or less prominent in the sample and adjusted the sampling procedure accordingly.

Participants

The 11 participants (9 women, 2 men) were aged 72-94 years. All the participants were born and raised in Denmark; nine lived alone while two lived with their spouse. They were diagnosed with various chronic health issues and had been referred to home-based OT due to occupational performance problems within self-care or productivity; eight were referred from a hospital while three had not recently been hospitalised. After discharge from OT, two participants did not receive any assistance, six received housekeeping assistance, while two received assistance with self-care and housekeeping. See Table 2 for details.

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Table 2. Demographic and clinical data of the participants.

Participant (anonymized)

Arne Bodil Camilla Dorthe Ellen Fie Gitte Hans Inger Jane Karen

Gender

Male Female Female Female Female Female Female Male Female Female Female

Age in years Mean 85 years

79 87 81 85 87 89 72 89 81 94 92

Living arrangement

With spouse Married

Alone Widowed

Alone Widowed

Alone Widowed

Alone Widowed

With spouse Married

Alone Widowed

Alone Always single

Alone Widowed

Alone Widowed

Alone Widowed

Housing Single-family house

Apartment Senior housing

Apartment Apartment Single-family house

Apartment Farmhouse Single-family house

Single-family house

Senior housing

Health issues Hemiplegia (right side): impaired walking and use of arm Fatigue HOSP

Shoulder fracture Pain Circulatory problems HOSP

Hip fracture Osteoporosis Osteoarthritis Circulatory problems HOSP

Hip fracture Pain HOSP

Severe arthritis Osteoporosis Fatigue Pain NOT HOSP

Heart disease Fatigue Circulatory problems Hearing loss HOSP

Hip replacement Osteoporosis Diabetes HOSP

Heart disease Fatigue Circulatory problems Hearing loss NOT HOSP

Hemiplegia (left side): cannot walk or use arm Hemiagnosia COPD Pain NOT HOSP

Hip replacement Fatigue Pain Slight memory problems HOSP

Shoulder and pelvic fractures Arthritis COPD PMR HOSP

Assistance with self-care

No No No No No No No No Daily @ No Daily @

Housekeeping assistance

Daily []

Less than weekly §

Less than weekly @

No Less than weekly @ §

Daily [] § No No Weekly @ Less than weekly §

Daily @

HOSP: the participant had been hospitalised prior to referral to home-based OT; NOT HOSP: the participant had not been hospitalised prior to referral; COPD: chronic obstructive pulmonary disease; PMR: polymyalgia rheumatica; @Home-care assistant; [] Spouse; § Private help

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Data collection Data were collected January-March 2017 using a semi-structured interview guide (Brinkmann and Kvale, 2015a; Crabtree and Miller, 1999) to investigate participants’ present occupational performance and expectations concerning their future performance, including participants’ individual experiences in relation to themes that were salient in their everyday life. The guide comprised briefing and debriefing, questions concerning biographic information, and five primary interview questions related to the two research questions as shown in Table 3.

Table 3. Interview guide.

Research questions Primary interview questions How do older adults experience their occupational performance post OT?

Will you tell me about what happened when you had OT in your home? Did you gain something from having OT? Will you tell me about your present everyday life, now that the occupational therapist does not come any more? Will you tell me if something is now helping you or making it harder for you to do the things you would like to do in your everyday?

What do older adults who have had home-based OT expect regarding their occupational performance in the future?

Will you tell me about what you think it will take for you to continue doing the things you like to do in your everyday?

The interviewer (TLN) aimed at obtaining rich descriptions: detailed and nuanced, and thick: of sufficient quantity (Fusch and Ness, 2015) and followed procedures described by Brinkmann and Kvale (2015a) and Olsen (2003) to engage the participants and to capture their experiences and views. The questions were short, broad, open, non-directional and easily understandable. Participants were encouraged to describe as precisely as possible what they experienced and felt and how they acted. The strategies active listening, periods of silence, and probing were used to encourage the participants to elaborate further. The PEO model (Law et al., 1996), which represented the OT professional preconceptions of the interviewer, helped to enable new perspectives to emerge through follow-up questions concerning personal, environmental and performance components. The interviews were conducted in the participants’ homes; they started with a briefing to establish relationship, lasted 30-100 minutes, were audio-recorded, transcribed verbatim by a student assistant and quality checked by TLN. Corrected versions and field notes were stored in NVivo (2015).

Data analysis The transcribed interviews were analysed in five steps using inductive content analysis (Dey, 1993; Morgan, 1993; Schreier, 2012). Firstly, TLN read transcripts of all interviews in full to gain an overall impression. Secondly, TLN built a data-driven coding frame, resulting in 21 codes (Table 4) (Schreier, 2012). Thirdly, TLN coded all material, i.e. sorted it by the 21 codes set up in NVivo (2015). Fourthly, the codes (Morgan, 1993) were categorised into nine subcategories and summarised into three descriptive main categories (Table 4), which are presented in the article’s findings

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section, accompanied by illustrative interview citations for transparency (Brinkmann and Kvale, 2015a; Dey, 1993). Finally, looking for patterns and co-occurrences across categories at the interpretive level (Morgan, 1993; Schreier, 2012) led to two explanatory syntheses, which are discussed in the article’s discussion section. No new codes emerged after the first six interviews, and each code was represented in at least three interviews.

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Table 4. Coherence between research questions, subcategories and codes, main categories, and syntheses.

Research questions Meaning units, citations in text

Subcategories and codes Main categories Syntheses

How do older adults who have had home-based OT experience their occupational performance post OT? (Research question 1)

A1 C1

Improved occupational performance 01) Improved performance related to OT aims 02) Untrained activities improved

Achieved improvements in occupational performance through OT

The importance of achieving and maintaining independence Strategies used to improve and maintain occupational performance

B1 F1 K1

Strategies adopted through OT that enhance occupational performance today 03) Adaptation of activities 04) Assistive devices and environmental adaptations 05) Problem-solving

H1 C2 E1 C2 C3

Consequences of improvements in occupational performance achieved through OT 06) Feelings of independence or freedom 07) Feelings of joy related to resumed occupations 08) Feelings of safety or comfort 09) Experiences of positive social impact 10) Negative consequences of improved performance

K2

Unresolved performance problems related to OT aims 11) Unresolved performance problems

Unresolved performance problems related to the OT intervention

I1 Consequences of unresolved problems 12) Feelings of unhappiness

E2 E2 K3

Strategies adopted to deal with the unresolved problems 13) Accepting the situation 14) Receiving help 15) Working to improve occupational performance

What do older adults, who have had home-based OT expect regarding their occupational performance in the future? (Research question 2)

J1 J2

Thoughts and feelings concerning future occupational performance 16) Confidence concerning future performance 17) Worries concerning future performance


D1 G1

Strategies used to maintain occupational performance 18) Continuing with important occupations 19) Keeping physically and mentally fit

B2 G2

Strategies to deal with decline 20) Adapting to decline 21) Knowing whom to contact

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Ensuring validity and reliability The sample consisted of a heterogeneous group of former participants in home-based OT. The validity of the interview guide was strengthened through discussions among all involved authors, and through two pilot interviews. The primary investigator, TLN, is an occupational therapist experienced in home-based rehabilitation of older adults. To ensure the face validity and reliability of the coding frame, all authors were involved in developing it (Schreier, 2012). A trial coding was performed by TLN and KSP, and codes used inconsistently were improved (Schreier 2012). To maximise validity of the analysis, all authors discussed the main aspects and interpretation of the findings. Step 1-4 of the analysis were performed on the Danish transcripts; translation of the citations from Danish to English were made from the original by TLN in cooperation with a bilingual professional translator (Van Nes et al., 2010). We aimed at obtaining rich and thick descriptions through the reported procedures for sampling, data collection, and analysis (Fusch and Ness, 2015).

Ethics

The study abided by the Declaration of Helsinki (World Medical Association, 2013). All participants were informed about the study and their rights, both orally and in writing, before giving written consent. The participants were anonymised in all documents used for further processing; original personal information was kept confidential and destroyed when no longer needed.

Findings

Three main categories were inductively derived from the coded material: ‘Achieved improvements in occupational performance through OT’, ‘Unresolved performance problems related to OT intervention’ and ‘Efforts to maintain occupational performance in the future’. Alphanumeric codes after citations refer to Table 4.

Achieved improvements in occupational performance through OT

Most participants stated that owing to OT they had improved their occupational performance. The improvements were within self-care, indoor and outdoor mobility, productivity and leisure.

Well, washing myself in the morning and all that, I manage that myself, you see. And taking a bath and all, that is also done quite automatically (Arne, A1)

Physical improvements were often related to improved occupational performance. Improvements in activities that had been practised during OT had enabled some to take up untrained activities like shopping, gardening or using public transport.

I can use a shopping trolley again; this is how well I walk now! (Camilla, C1)

The participants told how strategies adopted through OT were often still used to enable their occupational performance. Adaptation of activities was an important strategy; this could include resting intermittently, choosing ready-meals and using new techniques to compensate for impairments.

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I take my garbage bag, tie a knot on it, put it in my IKEA bag and carry this over my shoulder (…). I can then descend the stairs, holding on to the railing. (…) I would never have thought about this myself (Bodil, B1)

Other useful strategies involved using assistive devices, e.g. rollators, reachers or stocking aids, using labour saving household devices or making changes to the home environment. The participants found that such strategies improved their occupational performance, safety and mobility.

A small shower seat, it is so fine and small. It is not so polite to say this, but I find it hard to believe that it comes from the municipality (laughing), and they have also mounted a small grab bar that I can hold on to (Fie, F1)

Problem-solving in relation to activities had been discussed with the occupational therapist, and some of the participants continued themselves to find new, easier or safer ways of performing activities. Karen bought a small drying rack for her laundry and shared the laundry tasks with her daughter:

Now I can take it down. She hangs it up and I fold the dry clothes, I can do that (Karen, K1)

The participants had experienced mainly positive consequences from improving their occupational performance. Many valued highly that they could perform independently inside and outside the home again. Some emphasised not having to be dependent on others’ help any more, which they had perceived as a burden. Some had regained freedom to leave home when they wanted, to go wherever and whenever they wanted, and to decide independently what to do. Hans did not need help from a home-care assistant to get dressed anymore; this enabled him to make and keep early appointments in town again:

Now I do not need to stand [and wait] any more, I think I am freer now, with this [points at stocking aid] (Hans, H1)

Feelings of joy were related to resumption of occupations like going shopping, taking walks, cleaning, cooking one’s own food, and gardening. Positive social impacts were experienced, too. Examples included visiting the family again, taking up walks with friends and meeting friends in the supermarket.

Actually, you get to talk to different people [in the supermarket], instead of everything being the same all the time (Camilla, C2)

Feelings of safety or comfort were expressed. Ellen, who had her occupational therapist observe her bathing, said:

She … found that I did it as safely as it could be … it was actually very good, that she was satisfied with the way I did it (Ellen, E1)

Some negative consequences were also experienced. Camilla missed the home-care assistant, who no longer came to help her to bed, since this person used to encourage her:

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It was at the time when I could not yet climb to bed and all that myself. They [the assistants] always wanted to know: Have you been out walking today? Yes, Yes, I said, I surely have. Well, yes, that is good! (Camilla, C3)

Unresolved performance problems related to the OT intervention

In spite of improvements achieved through OT, the participants stated that a number of performance problems were still present. Unresolved problems existed in relation to self-care, mobility, productivity and leisure. Some activities were still not performed independently; other activities were performed independently again but with difficulty, with an (unwanted) assistive device, or less often than wished. Unresolved problems were linked to persisting physical problems like tiredness, impaired mobility or pain. Some refused to use assistive devices because they did not want to be reliant on them, although they acknowledged that they might be helpful. Sometimes, assistive devices did not fully solve the problems, and activities were therefore never resumed. Karen learned to dress herself, but, overall, it was too strenuous for her:

With much difficulty, when I had assistive devices, I could do it, but I cannot endure standing up for so long in the evening … it is painful (Karen, K2)

Unhappiness was felt in relation to unresolved problems like lack of energy due to extreme fatigue, feelings of helplessness due to immobility or lack of dignity due to inability to dress and undress oneself.

Alone and helpless … I sit here and cannot move around (Inger, I1)

Accepting the situation was a way of coping with the unresolved performance problems, and some participants told that their occupational therapist had helped them learn this. The participants compensated for unresolved problems by receiving help from spouses and other family members, private help or home-care assistants. Concerns about being too much of a strain on one’s spouse and family were also expressed as were feelings of relief.

The occupational therapist … could see it was very difficult for me to change the bed linen and hang up the washing, so I was allowed to have a home-care assistant do that. So in this way, she has been good (Ellen, E2)

Many participants continued practising activities to further improve their occupational performance and physical abilities. Some explicitly expressed a wish to improve to the extent that they could dispense with their assistive devices. Some mentioned specific, highly valued, yet untrained, activities performed outside the home that they wanted to resume like cycling, going to a beauty parlour, caring for grandchildren, taking up water aerobics, and visiting friends nearby or out of town.

She [the occupational therapist] urged me to do it [continue practising post OT] as much as I could, as that would be good for me, and I can feel that, too (Karen, K3)


The participants shared their thoughts and feelings concerning their future occupational performance, their strategies to stay active and ways of dealing with decline. Confidence

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concerning future occupational performance was expressed in general terms by some, while others were more specific:

I do not know if I can continue to squat as I used to when I weed the garden, but then I just have to find another solution (Jane, J1)

However, several participants expressed fears of losing their abilities and independence, fears of falling and of possible consequences like having to use a wheelchair or move to a care home. Fears of losing momentum in life and becoming housebound were also expressed. Several participants were concerned that they would lose the structure of their everyday life, and that they would end up staying in bed or watching television all day instead of living an active life.

I am terrified by the idea of having to sit and just watch [television] (Jane, J2)

Striving to continue important occupations was generally expressed. Many participants emphasised the importance of staying active, continuing what they could do themselves, and using skills accomplished through OT.

I look at it this way: you have to do what you can do, you have to do it yourself, right? (Dorthe, D1)

It was important to maintain specific leisure and social activities like taking walks, being with friends, gardening and reading. Having binding appointments with others could support activity. Striving to keep physically and mentally fit was often mentioned as a means of maintaining occupational performance.

I do not get it done [exercising] by myself. I simply have to go to a gym, and this social thing, I like to be in the group (Gitte, G1)

Accepting that one has to change former standards and habits, especially by downscaling activities and workload, was one way of adapting to a lower performance level, as was arranging to have more help for household activities and gardening.

Such habits as tending the flowers Wednesdays and Sundays, why, if you are exhausted on Wednesday, let those flowers be! (Bodil, B2)

Participants were aware that the need for rehabilitative services could arise again. Several expressed feelings of safety and comfort linked to knowing how to contact their occupational therapist again, and knowing which other municipal services were available. Gitte’s occupational therapist had prepared her for discharge:

[She] has been excellent at preparing me … among other things she came with all these pamphlets about … everything the municipality offers … I can return to those any time (Gitte, G2)

Discussion and implications

From the analysis across categories, two explanatory syntheses (Dey, 1993; Morgan, 1993) were derived: ‘Achieving and maintaining independence’ and ‘Strategies used to improve and maintain occupational performance’.

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Achieving and maintaining independence

Independence was highly valued and striven for by the participants. It was expressed as needing no assistance from others at all, as performing without assistive devices or in terms of performing specific activities by oneself. Achievements in occupational performance were linked to improved independence and to feelings of freedom and joy. When occupational performance had not improved as much as wished for, participants expressed concerns about unwanted dependence, and many therefore still strove to improve their occupational performance post OT. A similar emphasis on independence among older adults is reported by other studies (e.g. Mack et al., 1997; Randström et al., 2013; Yuen et al. 2007). Also in line with our findings, previous studies have shown that receiving help from a public home-care service was associated with reduced self-determination (Hammar et al., 2016) and reduced life satisfaction (Johannesen et al., 2004). However, participants of the present study could also negotiate degrees of independence, where minor improvements and implementation of acceptable ways of working around persisting problems could be experienced as satisfying. Yuen et al. (2007) have found that community-dwelling older adults may redefine their perceptions of independence and dependence as their functional performance declines. Gignac and Cott (1998) have proposed trying to understand what physical independence and dependence means to individuals and what factors contribute to these perceptions. They suggest that in some areas of life, independence may be possible only by accepting some level of dependence in other areas of life. We suggest that occupational therapists employ these understandings to help older adults arrive at an acceptable trade-off between independence and dependence. Some participants in the present study performed housework together with family members or a hired help and found it more dignifying than passively receiving help. ‘Doing together with others’ has previously been reported (e.g. Bergström et al., 2015) and could be proposed when older adults cannot achieve independent performance of valued occupations. Setting OT goals that aim at ‘having no need for assistance’ may lead to discouraging results within home-based OT for older adults with chronic health issues. Instead, it can be addressed that full independence may not be achievable, by negotiating two degrees of the goal: a) the desired level of independent performance, e.g. ‘cooking a family dinner independently’, and b) the minimally acceptable degree of goal fulfillment, e.g. ‘cooking a family dinner with help to drain the potatoes‘.

Strategies used to improve and maintain occupational performance

The participants valued discussions with occupational therapists about solving various performance problems. Dawson et al. (2009) suggest that problem-solving strategies be implemented into daily occupational performance in three phases: acquisition (learning to use a strategy for a specific activity during OT sessions), generalisation (using the strategy for the same activity outside sessions) and transfer to other goals. Sufficient time is required for this process in order for problem-solving to become a fruitful strategy in older adults’ everyday lives. In the present study, some participants had continued problem-solving post OT, while others seemed less capable of this. Problem-solving comes more naturally to some than others, and teaching problem-solving strategies may be worth emphasising in OT programmes for older adults.

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Assistive devices implemented during OT as a compensatory strategy were perceived by some participants as supporting the maintenance of occupational performance post OT. However, a number of participants worked on dispensing with their devices because they feared that using them would lead to further loss of abilities and to future reliance on them. Lund and Nygård (2003) describe users of assistive devices as pragmatic, ambivalent or reluctant users and link the descriptions to different adaptive approaches to achieving a desired occupational self-image. To the reluctant user, the undesirable consequences of using assistive devices may result in withdrawal from valued occupations. We find that occupational therapists should acknowledge and address older adults’ desired self-image and any reluctance when suggesting assistive devices as a means of enabling occupational performance. Use or non-use should be discussed and linked to the older adult’s general wish to be independent in everyday life. Practising activities was the main strategy used during OT, and it was obviously transferred by many participants to dealing with unresolved problems post OT. The participants expressed a strong wish and determination to continue performing important activities in the future. Previous research conveys similar results (Bergström et al., 2015, Vik and Eide, 2014). The high degree of motivation among our participants to improve and maintain occupational performance post OT is important, bearing in mind the challenges related to maintaining achieved improvements raised in the introduction. Yet, such high levels of motivation are not always present or sufficient to maintain the desired occupational performance. Some participants valued knowing how to contact their occupational therapist again, others were uninformed. Follow-up visits at individual intervals could be scheduled with the occupational therapist upon discharge to address any unresolved or newly arisen performance problems and to brush up on or adapt strategies. Healthcare professionals, including occupational therapists, involved in services for older adults should continue to look out for risks related to, or manifest declines in, occupational performance. Future studies may explore how to detect which older adults are in need of a follow-up visit.

Bodily strength and mobility were practised during OT and in physiotherapy, and many participants continued this activity, seeing it as a means of maintaining future occupational performance. This strategy has also been found in other studies among home-dwelling older adults (Vik and Eide, 2014; Yuen et al., 2007).

From our findings and this discussion, ways of accommodating older adults’ aspirations for improvement and maintenance of occupational performance post OT can be proposed. We posit that independence can be negotiated, goals that do not specify full independence can be formulated, and acceptable, alternative ways of accomplishing desired occupations can be explored. Emphasis can be put on problem-solving strategies during OT, giving the necessary time for generalisation and transfer. Occupational therapists should identify and address older adults’ possible reluctance when suggesting assistive devices. Follow-up home visits post OT may support occupational performance in the home. Such initiatives need to be evaluated in future studies.

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Limitations

Only two men participated in the study; yet, their different living situations added to the variation. Some gender-specific differences apply to performance problems (Källdalen et al., 2012) and perceived satisfaction with participation (Vik and Eide, 2014), and had we been able to include more men, further aspects of older men’s experiences might have emerged. No participants lived with their family or were born and raised outside Denmark; we cannot be sure how the results and the suggestions have relevance in their situations. Those participants who had much help from a spouse or from family expressed confidence concerning their future performance despite unresolved performance problems. Older adults with help close at hand may accept a higher degree of dependence which, in turn, may negatively affect their motivation for OT and the long-term effectiveness. The semi-structured individual interviews enabled us to achieve rich and thick descriptions of experiences of everyday life post OT. The reported positive influence of OT, unresolved problems, useful and less useful strategies provided us with a breadth of experiences. The experiences can inform future practice about strategies for maintaining occupational performance. The present study did not evaluate long-term effectiveness of OT, as the interviews were performed 2-11 weeks post OT. The participants may have experienced improvements as well as deteriorations in their occupational performance during the following months. Follow-up interviews could further explore changes in occupational performance post OT. Our rich data and the focus on transparency in the analysis strengthen the internal validity of our findings. The syntheses and propositions concerning OT practice build on this evidence, as well as on previous empirical findings and theoretical work. According to Brinkmann and Kvale (2015b), ‘analytical generalisation involves a reasoned judgment about the extent to which the findings of one study can be used as a guide in another situation’. Our propositions cannot be transferred directly to OT for older adults who live with their family, are of non-Danish origin or have mental health issues or dementia. Yet we suggest that they may be generalised analytically to home-based and occupation-based OT for older adults with chronic physical health issues, who live alone or with a spouse in a Western welfare state. Conclusion and recommendations

The research questions addressed older adults’ experienced occupational performance post OT and their expectations concerning their occupational performance in the future. The study sheds novel light on everyday life experiences among home-dwelling Danish older adults with chronic physical health issues, who live alone or with a spouse, and on how they self-manage and solve their problems. The desire to achieve and maintain independence as well as acceptance of different degrees of independence were key findings, along with strategies learned from OT that were still used to improve and maintain occupational performance. Our participants’ input can inspire occupational therapists to plan and perform home-based interventions for older adults aiming at greater long-term effectiveness as they point to new ways of maintaining improvements. The following propositions for service development need testing to ensure effectiveness and applicability: working with ways of achieving satisfying occupational performance that do

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not necessarily entail becoming fully independent; increasing focus on the use and transfer of problem-solving strategies; acknowledging and dealing with possible reluctance to use assistive devices; and offering individually scheduled follow-up visits post OT.

Key findings

Independence was a core theme among older adults, but different degrees of independence were accepted.

Strategies learned from OT were used to improve and maintain occupational performance post OT.

What the study has added

This study suggests an increased focus on problem-solving strategies during home-based OT and follow-up visits post OT by occupational therapists to help enhance and maintain older adults’ occupational performance.

Acknowledgements

Gratitude is extended to the participants and to the staff who helped with the sampling.

Research ethics

Ethics approval was obtained from the Danish Data Protection Agency in 2017 (trial identifier J.nr. 2017-41-4995). The Scientific Ethics Committee of Central Denmark Region deemed that no further approval was required (Query number 12/2017). All participants provided written informed consent.

Conflict of interest

The authors declare that there is no conflict of interest.

Funding

Funding was received from the Danish Association of Occupational Therapists (Grant number FF 1 17 – R45-A1276); VIA University College; and Aarhus University, Department of Public Health.

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Appendix 4

Appendix 4. Intermediate Analysis between Stage 1 and Stage 2

Process findings related to OT interventions

Occupational performance, outcome from OT interventions

Generalised questions

Study I RCT [2]

A wide array of activities within self‐care, productivity and leisure were chosen to be worked on during ICC‐OT, each type took up about a third of the interventions. Different therapeutic strategies were combined

Baseline to 3 months: Between‐group improvements (=effectiveness): ICC‐OT effectively improved self‐reported occupational performance compared to usual practice, but not satisfaction nor observed motor and process abilities. Improvements were largest among older adults with better self‐reported general health at baseline. Within‐group improvements in the ICC‐OT group were found concerning reported satisfaction and observed motor abilities. Baseline to 6 months: Between‐group improvements (=effectiveness): ICC‐OT effectively improved self‐reported occupational performance and satisfaction and observed motor abilities compared to usual practice. Within‐group improvements in the ICC‐OT group were also found concerning observed process abilities. 3 months to 6 months: Within the ICC‐OT group, improvement in self‐reported occupational performance had diminished (mean decrease 0.49 points, 95% CI 0.05 to 0.93, p 0.029), whereas there was no change in the usual practice group (mean change 0.00 points, 95% CI ‐0.46 to 0.46, p 0.998).

How do older adults who have received home‐based and occupation‐based OT experience their occupational performance after discharge? Which strategies (including strategies learned during home‐based OT) may older adults find useful or not useful to their occupational performance after discharge? How do they experience and address unresolved performance problems?

Study II Lit. review [3]

In 5 of 6 studies, ways to ensure client‐centred OT were described The interventions were to a large extent occupation‐based Different therapeutic strategies were combined

Short term: improved occupational performance in five of six studies, but also insignificant results on some assessments. Long term: Only four studies reported long‐term effectiveness. Improvements in self‐care (ADL) were lost at long term. Improvements in productivity (IADL) were maintained in two of three studies. No improvements in leisure activities at any time point. In one study, no effectiveness was found at any time point.

What do older adults expect concerning maintenance of occupational performance in the future? What enhances or hinders their maintenance of occupational performance? Which strategies may they find useful in relation to their expected future occupational performance?

Qualita‐tive evidence of user perspec‐tives [41‐43]

The home setting was mainly found convenient [41‐43] To try out activities in the natural context enhanced safe activity performance and increased confidence [41,43] Goal setting was experienced as collaborative, but the collaboration broke down regarding ways of reaching goals [41] The process of actively doing was linked to confidence building and independence [42] In one study, all participants felt discharge came too soon; they felt they could have achieved more if given more sessions [41]

Improvements in functional, social, and leisure issues [42] Adapting to the loss of former occupations, finding new occupations and roles, expanding former roles, and re‐entering social life [41] Psychological and emotional improvements [42] Some goals remained unobtained or had not moved forward [42] No studies were found concerning how older adults expect their future occupational performance to be after they had received client‐centred and occupation‐based OT in their homes.

Final Dissertation Tove Lise Nielsen 21 03 18 · Epidemiology Group, Aalborg University, Denmark...

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