MASTER IN DE ERGOTHERAPEUTISCHE WETENSCHAP · 2015-11-06 · Academiejaar 2014-2015 MASTER IN DE...

Faculteit Geneeskunde en Gezondheidswetenschappen

Development, validity and reliability evidence

for the Flemish version of the Life Balance Inventory

in people with multiple sclerosis

-

Hélène Dirix

Masterproef ingediend tot

het verkrijgen van de graad van

Master of science in de ergotherapeutische wetenschap

Promotor: Prof. Dr. Daphne Kos

Copromotor: Sven Van Geel

Academiejaar 2014-2015

MASTER IN DE ERGOTHERAPEUTISCHE WETENSCHAP

Interuniversitaire master in samenwerking met:

UGent, KU Leuven, UHasselt, UAntwerpen,

Vives, HoGent, Arteveldehogeschool, AP Hogeschool Antwerpen,

HoWest, Odisee, PXL, Thomas More

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Abstract – Dutch

Doelstelling: Sinds het ontstaan van de discipline occupational science is balans al één

van de kernconcepten maar er zijn niet veel instrumenten beschikbaar die dit construct

meten. De Life Balance Inventory (LBI) werd vertaald naar het Nederlands. Mensen met

MS ervaren minder life balance in hun leven, dit maakt het interessant om te onderzoeken

of er betrouwbaarheids- en validiteitsevidentie gevonden kan worden omtrent de LBI en

personen met MS.

Methode: Dit is een kwantitatieve studie die de psychometrische kenmerken van de LBI

tracht te bepalen, 22 proefpersonen namen deel. Ze vulden elk twee maal de LBI in en bij

de eerste afname ook drie testen die gerelateerde concepten van life balance meten.

Resultaten: Er werd een hoge graad van test-hertest betrouwbaarheid gevonden (ICC:

0,641 – 0,904). De Cronbach’s alpha werd berekend en toonde een hoge interne

consistentie aan (α = 0,825). Er werden correlaties gevonden tussen de LBI en de

subschalen en de DASS-21 (r = -0,447 – -0,827) en de PWI-A (r = 0,374 – 0,694). Er

werden geen correlaties gevonden tussen de LBI en de BPNS. Een secundaire analyse

toonde ook geen verschillen binnen de demografische categorieën.

Conclusie: De gevonden evidentie in deze studie draagt bij tot de bruikbaarheid van de

Vlaamse versie van de Life Balance Inventory en het internationale onderzoek omtrent

de LBI en het LBM. Het gebruik van het concept life balance kan zo uitgroeien tot een

van de kernaspecten van ergotherapie in Vlaanderen.

Key words: ergotherapie, life balance, life balance inventory, multiple sclerose,

psychometrische kenmerken

Aantal woorden masterproef: 12.197 (exclusief inhoudstafel, bijlagen en bibliografie)

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Abstract – English

Objective: Balance is one of the core concepts since the beginning of occupational

science, but not many assessment instruments are available that measure this construct.

The Life Balance Inventory (LBI) was translated into the Flemish language. People with

MS experience lower levels of life balance, which makes it interesting to examine

whether or not reliability and validity evidence can be found regarding the LBI and MS-

patients.

Method: This study tries to determine the psychometric properties of the LBI, 22

participants participated. They all have to fill in the LBI twice and had to fill in three other

tests that measure related concepts of life balance during the first test moment.

Results: A high degree of test-retest reliability was found (ICC: 0,641 – 0,904). The

Cronbach’s alpha was calculated and showed a high internal consistence (α = 0,825).

Correlations were found between the LBI and its subscales and the DASS-21 (r = -0,447

– -0,827) and the PWI-A (r = 0,374 – 0,694). No correlations were found between the

LBI and the BPNS. Secondary analysis showed no difference within the different

demographical categories.

Conclusion: The results of this study contribute to the usefulness of the Flemish version

of the Life Balance Inventory and the international research regarding the LBI and LBM.

Using the construct of life balance in daily practice can become one of the core concepts

of occupational therapy in Flanders.

Key words: life balance, life balance inventory, multiple sclerosis, occupational therapy,

psychometric properties

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Table of Contents

Abstract – Dutch ............................................................................................................... 5

Abstract – English ............................................................................................................ 7

List of tables ................................................................................................................... 10

Acknowledgements ........................................................................................................ 11

1. Introduction .............................................................................................................. 13

2. Research question .................................................................................................... 27

3. Method ..................................................................................................................... 29

4. Results ...................................................................................................................... 37

5. Discussion ................................................................................................................ 45

6. Recommendations for further research .................................................................... 53

7. Conclusion ............................................................................................................... 55

References ...................................................................................................................... 57

Appendixes ..................................................................................................................... 67

Appendix 1: Search strategy review of literature ........................................................... 69

Appendix 2: Information letter ....................................................................................... 71

Appendix 3: Informed consent ....................................................................................... 75

Appendix 4: Life Balance Inventory (Flemish version) ................................................. 77

Appendix 5: Demographical questionnaire .................................................................... 81

Appendix 6: DASS-21 (Flemish version) ...................................................................... 83

Appendix 7: PWI-A (Flemish version) .......................................................................... 85

Appendix 8: BPNS (Flemish version) ............................................................................ 87

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List of tables

Table 1: Demographic characteristics…………………………………………………..37

Table 2: List of descriptives…………………………………………………………….39

Table 3: Correlation coefficients………………………………………………………..39

Table 4: Wilcoxon Signed Ranks Test results…………………………………………..40

Table 5: List of correlations.……………………………………………………………42

Table 6: Results of the Levene’s tests statistic and ANOVA……………………...…….43

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Acknowledgements

Finally, after two years of studying, the work is done! With proudness I present you my

thesis: ‘Development, validity and reliability study of the Flemish version of the Life

Balance Inventory in people with multiple sclerosis’.

The last two years haven’t been easy but I’ve learned a lot. It have been the most busy

years of my life and sometimes it wasn’t easy to achieve balance in my life. Due to this

master’s program, my vision as an occupational therapist is highly enriched. I feel like

I’m ready to step into the world as a full professional. I hope that my research can

contribute to the (further) development and research about the concept of life balance but

as well to the bigger picture of ‘occupational science’.

I would like to thank everyone for their support and trust in me, for some not only the last

couple of months but the last couple of years. I would like to thank the following people

in particular.

First, I would like to thank my promotor Dr. Daphne Kos. Thank you for all the help and

advice when I needed it, for always reading my text critically and giving feedback, for

starting the translation of the LBI and for making it possible to gather my data in the

National MS-Centre at Melsbroek.

Also thank you to my copromotor Sven Van Geel for giving me advice about the subject,

for starting the translation of the LBI and for proposing this subject as a master’s thesis

subject. It has been a pleasure to do something that I’m committed to.

I would like to thank the National MS-centre at Melsbroek for letting me gather my data

in their setting and the occupational therapy department for letting me use their therapy

hours to conduct my data. I thank Karen Verbeek in particular, she helped me finding the

participants and always helped when I was in need or had some questions.

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Of course I would like to thank all the participants, without you I couldn’t have done this

research. Thank you for letting my use some of your valuable time and for sharing all this

information with me.

A special thanks goes out to all of my friends and family. Thank you for listening to me,

for giving me advice, for your support and for always being there when I needed you!

They say ‘save the best for last’, so the last ones I’d like to thank are my mom and dad.

Thank you for always believing in me even when it didn’t seem like everything was going

to be all right. Thank you for giving me the chance to do all of this. Without you, I never

could have done what I did and I would never have achieved what I achieved the last

couple of years.

Thank you all, I hope you enjoy reading my thesis!

Hélène Dirix

3th of May 2015

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1. Introduction

1.1 Balance

The idea of a balanced life has existed for a long time. Hippocrates (c. 500 B.C.) said that

the balance of four humors was related to a healthy life. Galen (131 – 201) expanded this

idea, proposing that a balance of the ‘passions’ was essential for physical health

(Sternberg , 1997). Different disciplines have been interested in this concept for example:

sociologists are interested in the ways people seek their balance between the demands of

their work and family. Anthropologists want to know how cultures prescribe and limit

their roles and occupations (Westhorp, 2003). Other cultures, ranging from Chinese

medicine to Native American healing believe that health requires a balance among

thoughts, actions and feelings, and that the environment provides the people opportunities

and challenges for maintaining their well-being and for meeting their needs (Alter, 1999).

Occupational science is the field that is interested in balance. Occupational scientist are

interested in the ways humans use a variety of occupations to: meet the demands of their

culture and society, develop skills, achieve satisfaction and maintain healthy

(Christiansen & Mautska, 2006; Westhorp, 2003). The focus of occupational science is

how daily activities influence health and well-being (Larson & Zemke, 2003). Many

authors state that occupational balance can be one of the key concepts in the area in which

occupational therapists try to determine the relationship between engagement in

occupations and health (Christiansen & Matuska, 2006; Meyer, 1922/1977, Reilly, 1977).

People use occupations in order to achieve a sense of being the person they want to be,

as well to cope with the demands of their roles (Christiansen & Matuska, 2006). The

pressure to be capable and efficient, and respect for one’s values, needs and resources as

well, can affect engagement in occupations (Hakansson, Dahlin-Ivanoff & Sonn, 2006).

Balance has been one of the core concepts to develop a base of knowledge about human

occupation(s) since the beginning of occupational science (Christiansen, 1996). But the

concept of balance has a much larger history within occupational therapy. Meyer

(1922/1977), said that everyone needed a balance between the ‘big four’ – work and rest

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and play and sleep – (Westhorp, 2003). He did not mention anything about whether this

balance indicated equal amounts of time or not.

Since the concept of balance has been introduced, many have tried to describe this

concept. Popular media promotes the necessity to achieve: ‘balanced lives’ and ‘balanced

diets’. The time-pressure related to the modern life in western cultures have increased the

public interest of how life styles can be managed (Christiansen & Matuska, 2006). There

is a growing interest in developing an understanding, from an occupational perspective,

of the experience of life balance (Hakansson et al., 2006). Yet, 25 years later, there is no

consensus, definition, model or measure (Backman, 2004; Christiansen & Matuska, 2006;

Westhorp, 2003). Sheldon et al. (2010) suggest that it is almost impossible to define and

measure a concept with a theoretical weight that has been placed upon it from ancient

times to the present. But Wilcock et al. (1997) claim that an evaluation of a client’s

perceptions of their balance between all of their occupations in their present and future

lifestyle should become a part of standard occupational therapy-practice.

As noted earlier, the roots of balance within occupational therapy go back to Meyer

(1922/1977) but more recently many authors tried to explain and create a model to

understand and theorise the concept of balance. Christiansen (1996) claims in order to

achieve well-being work, leisure, self-maintenance, and sleep should be distributed

equally over the day. But the number of occupations and the amount of time spent in each

occupation does not have to be equal. Kielhofner (2002) states that balance in everyday

life would reflect a dynamic interconnection of the occupational domains and their

relationship to interests, internal values, and goals. He further claims that there is a

dynamic relation with the external demands of the environment as well. Westhorp (2003)

states that people undertake change in their occupations to achieve some kind of harmony

which can lead to states of calmness, mental steadiness, and improved health and well-

being. Pentland & McColl (2008) have another view on occupational balance, they state

that the concept doesn’t include the underlying choices that lead to occupations. The

underlying idea of life balance is living congruent with one’s personal meaning and

values. They call this ‘occupational integrity’.

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Christiansen and Matuska (2008, 2012a) proposed a model about balance: ‘the Life

Balance Model’. It builds on the research about the psychological and psychological

attributes that are considered important for well-being. The model also underlines the

importance of the interaction between the individual and the environment (Matuska,

2010).

Hakansson et al. (2006) suggest that there are four factors that influence each other, which

can either lead to balance or imbalance. Those four factors are: (1) Image of occupational

self, (2) Strategies to manage and control everyday life, (3) Occupational repertoire, and

(4) Occupational experience, this includes the participants’ own meaning and

interpretations of their daily occupations.

Stamm et al. (2009, p33) used the following definition: ‘occupational balance means to

be engaged in different types of occupations in a dynamic way so that this individual mix

of occupations leads to health and to high quality of life as experienced by the individual’.

They developed three dimensions of occupational balance: (1) Challenging versus

Relaxing Occupations and Activities, (2) Activities Meaningful for the Individual and

Activities Meaningful in a Sociocultural Context, (3) Activities Intended to Care for

Oneself and Activities Intended to Care for Others. They claimed that occupational

balance does not necessarily require being engaged in paid work but rather being engaged

in challenging activities and any kind of productivity (Stamm et al. 2009).

A more recent review of Wagman, Hakansson & Jonsson (2015) contained 22 articles

regarding occupational balance between 2009 and 2014. They found out that there is a

major geographic gap in the area where occupational balance is researched. Almost all

the publications were from Sweden and Canada. Their overall conclusion was that the

inclusion of occupations that are linked to people’s own interests and joy, seems to be

very important for experiencing occupational balance. An optimal variation within the

daily occupations is important as well. The authors stated that more research is needed

regarding the difference between occupational balance and life balance although they

wondered if there even is a difference. Sheldon, Cummings & Kamble (2010) did go even

further, they wondered if we need a theoretical construct of life balance. They asked

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themselves whether or not that there already is another name or phenomena that describes

the same?

Even though there is no consensus about life balance, many research has shown that

balance can have an influence on health and well-being, either positive or negative. It is

an important aspect of the health experience (Christiansen & Matuska, 2006; Hakansson,

et al., 2006; Hakansson, Lissner, Björkelund & Sonn, 2009; Wagman et al., 2015;

Wilcock et. al, 1997). Overall health seems to be influenced by engagement in

occupations (Canadian Association of Occupational Therapists, 1994). These findings

make it interesting for occupational therapists to use this as one of their core businesses.

Making people agents rather than victims of their daily lives is the role of meaningful

occupations (Hakansson et al., 2006).

As described above, there are multiple ways and models that describe some kind of

balance. This paper and research will be conducted on the basis of the Life Balance Model

and the Life Balance Inventory from Matuska and Christiansen.

1.2 The Life Balance Model (LBM) & Life Balance Inventory (LBI)

1.2.1 Life Balance Model (LBM)

The LBM is a theoretical model that supports the concept of life balance and imbalance

by Matuska and Christiansen (2008). It has been developed on interdisciplinary research

about the psychological and psychological attributes that are considered important for

well-being (Christiansen & Matuska, 2006). It was created upon the theories of Maslow

(1943), Ryff (1995), Ryff & Singer (1996) and the Self Determination Theory from Deci

& Ryan (2000) (Matuska & Christiansen, 2008). The model suggests that certain

configurations are considered balanced or imbalanced depending on whether the needs of

a person are met (Matuska, 2010; Matuska, 2012a).

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The model describes life balance as: ‘A satisfying pattern of daily activity that is healthful,

meaningful, and sustainable to an individual within the context of his or her current life

circumstances’ (Matuska & Christiansen, 2008, p. 11).

Satisfying: the amount actually spent on participating in activities and the amount

of time one would like to spend is equally distributed;

Healthful: activities contribute to both psychological and mental health;

Meaningful: activities engaged in are important;

Sustainable: activity configurations can be maintained over a long term (Matuska,

2010).

Life balance is expected to relate to lower stress, higher need satisfaction and higher

personal well-being. The model suggests that people who participate in activities that

meet all of the need-based dimensions will perceive their lives as less stressful, more

satisfying, and more balanced (Matuska, 2012b).

In order to engage in everyday activities activity configurations are required. The model

suggests that all these activities should help people to: (1) meet basic instrumental needs

necessary for sustained biological health and physical safety; (2) have rewarding and self-

affirming relationships with others; (3) feel engaged, challenged, and competent; (4)

create meaning and positive identity (Matuska & Christiansen, 2008). There is also a fifth

need-based dimensions: (5) to organize their time and energy in ways that enable them to

meet important personal goals and renewal. Time and energy are viewed as the key

dimensions in the model because they contribute to the creation of meaning (Matuska,

2010).

The balance part of the model focuses on ‘activity configurations’ which means that there

should be an equal proportion of satisfaction with time use across various activities that

meet the model’s four need-based dimensions (Matuska, 2012a). The activity

configurations are divided into two components: ‘activity configuration congruence’ and

‘activity configuration equivalence’. There is an overlap between these two because both

are necessary for a balanced life (Matuska & Christiansen, 2008). Congruence means that

one’s actual activity configurations matches one’s desired activity configurations.

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Equivalence allows people to meet the four need-based dimensions through their activity

configurations. High equivalence means that there is an equal proportion of time use

(congruence) across various activities that meet the need-based dimensions of the LBM

(Matuska, 2010). The activity configurations vary for individuals across situations and

time because people have different roles and role requirements in different situations

(Matuska, 2012a; Matuska, 2012b).

The model suggests that there is an environmental context as well. This context includes:

the physical, social, cultural, political and economic, and temporal context. The

interaction between the person and his or hers environment is dynamic (Matuska &

Christiansen, 2009). See figure 1 for a visual representation of the Life Balance Model.

Figure 1: The Life Balance Model (Matuska, 2010)

When people can experience life balance, there is always the possibility to experience life

imbalance. The model describes this as a configuration of daily activities that do not

satisfy the individual and which: (1) increase the risk for both physical and mental health

problems, (2) limit or compromise participation in valued relationships, (3) do not

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establish or maintain a satisfactory identity, (4) are felt to be boring, uninteresting or

unchallenging, (5) or are not enough organized to enable goals achievement or self-

renewal (Matuska, 2009; Matuska & Christiansen, 2009).

1.2.2 Life Balance Inventory (LBI)

After the Life Balance Model (LBM) was created, the LBI was created, it can be used for

research, but also for personal assessment of life balance that could inform individuals

about the balances and imbalances in their lives (Matuska, 2010; Matuska, 2012a).

This assessment contains 53 items that represent the range of activities in which people

in western cultures can engage (Matuska, 2012a). It tries to capture how individuals meet

their needs through daily activity configurations (Matuska, 2010). It is built to measure

congruence (mean score across all items respondents do or want to do) and equivalence

(mean scores of the subscales) (Matuska, 2010; Matuska, 2012b). The author used the

basic categories of daily living: instrumental activities of daily living, work, rest, play,

education, leisure, and social participation for creating the activity categories. There were

three important principles that guided the development of the LBI:

The configurations of daily activities are unique to each person;

Imbalance can result from spending too little or too much time in one or more

activities;

The activity categories in the scale reflect the need-based dimensions of the LBM

(Matuska, 2012b).

The LBI contains four subscales that are linked to the need-based dimensions of the LBM:

(1) Health subscale (ex. Relaxing, getting regular exercise, …), (2) Relationship subscale

(ex. Doing things with friends, partner, …), (3) Identity subscale (ex. Taking care of your

appearance, participating in religious events, …), (4) Challenge/interest subscale (ex.

Working for pay, making music, …) (Matuska, 2010).

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The instrument contains 53 activities and on a dichotomous scale of yes/no, people have

to answer, whether or not they do the activity or want to do the activity. For each item

that they scored ‘yes’, they have to rate their satisfaction with the amount of time they

have spent doing that activity in the past month compared to the amount of time they

wanted to do the activity. The possible answers are: “always less than I want, sometimes

less than I want, about right for me, sometimes more than I want, always more than I

want” (Matuska, 2010; Matuska, 2012a). This scoring method makes it possible to

individualizes the results to reflect the unique activity configuration of each individual.

The satisfaction rating reflects the fifth dimension of the LBM (Matuska, 2010).

1.2.3 Evidence regarding the Life Balance Model and the Life Balance Inventory

The articles described in this section are the ones that either involve the LBM, the LBI or

both. Most of the research has been conducted in Sweden or the United States (Hakansson

& Matuska, 2010; Matuska, 2012b; Matuska, Bass & Schmitt, 2013; Matuska &

Erickson, 2008; Stein, Foran & Cermak, 2011; Wagman, Hakansson, Matuska, Björklund

& Falkmer, 2012). The concept of life balance have been examined within different

groups: women with MS (Matuska & Erickson, 2008), the American population

(Matuska, 2012a; Matuska, 2012b; Matuska et al. 2013), the working Swedish population

(Wagman et al., 2012), Swedish women with a stress-related disorder (Hakansson &

Matuska, 2010), and parents of children with autism (Stein et al., 2011). All of the studies

provided validity evidence for either the LBM, the LBI or both, yet some differences were

found between the groups.

Matuska & Erickson (2008) explored how women with MS experience their disease and

how they feel about their lifestyle balance. Participants said that life balance is a

continuous challenge, they have to make frequent adaptations in their lifestyle and/or

physical and social environments. People with MS constantly have to make choices

whether they an activity or not because doing multiple activities would be too hard and

tiresome. Mostly they would do the occupations that they considered necessary and did

not always have energy left to meet their other needs. Dimension 5, was seen as an

overwhelming challenge because of their severe fatigue. Yet, the participants could relate

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to all five of the need-based dimensions and so this provided validity evidence for the

LBM. The same results were found in a study with Swedish women recovering from a

stress-related disorder (Hakansson & Matuska, 2010). Participants felt like they were

always balancing between a balanced and imbalanced life. They became more ill when

they experienced more stress and anxiety due to their imbalanced life. All of the need-

based dimensions influenced their balance but also felt like the fifth dimension of the

LBM was the most challenging. In contrast to the women with MS they felt like they

regained control over the occupations that were most important when they made active

choices about how to spend their time and energy.

Both studies described above have recruited female participants with a health condition.

Yet, the Life Balance model should also be applicable to the general population. Wagman

et al. (2012) interviewed 19 participants from the general Swedish population on their

perception of life balance and the LBM. The participants reported that each need-based

dimensions was important for their life balance, health and well-being. While they related

imbalance to ill-being, the participants indicated that there was an additional dimension

that was not reported in the LBM: financial security. They said that financial security can

be contribute to and/or affect life balance.

Stein et al. (2011) used the LBM in order understand the life experiences of parents of

children with autism spectrum disorder. They concluded that the LBM could be a good

way to describe life balance but suggested a refinement of the model because of the

complex relationships between the five dimensions. The authors concluded that some

dimensions were difficult to separate as some constructs appeared to overlap in the

autism-population.

After creating the LBM and the LBI, Matuska (2012b) conducted two quantitative studies

to test the validity of both the model and the measure. Matuska (2012b) conducted no

separate study to determine the validity of the LBM. She claimed that the model would

automatically gain validity evidence when the results of the reliability and validity study

of the LBI were good. This because the LBI is created upon the constructs of the LBM,

thus the constructs of the LBM would be validated as well by only validating the test.

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The pilot test included 282 people (90% women); the analysis showed that the items of

the LBI captured a wide range of activities and that the items fit with the LBM. The

second study included 458 participants who had to complete the LBI together with the

Depression Anxiety Stress Scales-21 (to measure perceived stress), Personal Wellbeing

Index-Adult (to measure quality of life and well-being), the Basic Psychological Needs

Scale (to measure the level of competence, autonomy, and relatedness) and a

demographic questionnaire. The results showed that:

Congruence is positively associated with personal well-being (r = .49), and basic

psychological need satisfaction (r = .62), competence (r = .67), and autonomy (r

= .86). Congruence was negatively related with stress (r = -.40).

The equivalence part of model is not as favourable as the congruence part of the

model.

Equivalence showed to be significantly related to congruence but not to the other

variables. A fit of the congruence and equivalence model seemed the best fit.

A secondary analysis was drawn from the online database with completed surveys of the

LBI by Matuska et al. (2013) to see which demographic profile had the highest life

balance and to see if life balance predicted perceived stress. Results showed that the

profile with the highest life balance was: white, 61 years or older, had a master’s degree,

lived in the suburbs, had two children, was not working, owned a home and lived in the

United States. They also stated that females had significantly lower LBI Identity subscale

scores and significantly higher stress scores than males. Further analysis showed that

higher life balance scores predicted lower perceived stress scores.

1.3 Other assessment regarding balance

Apart from the LBI, very limited assessment instruments regarding balance are available.

It is difficult to capture a construct that has no general definition in a measure. More

recently, three measurements have been developed and tested: the Meaningful Activity

Wants and Needs Assessment (MANWA) (Eakman, 2015), the Occupational Balance

23

Questionnaire (OBQ) (Wagman & Hakansson, 2014) and the Occupational Balance-

Questionnaire (OB-Quest) (Dür, et al., 2014).

The Occupational Balance Questionnaire (OBQ) is an instrument that measures

occupational balance. The conceptual framework for this instrument is based on results

from previous research regarding balance. The instrument focuses on the variation in the

occupational patterns, the meaningfulness in the occupations and the amount of each

occupation and the total amount of occupations in relation to the available ones. The

authors state that all these aspects are necessary to experience occupational balance

(Wagman & Hakansson, 2014). The OBQ consists of 13 items, each one is measured on

a six-step ordinal scale, ranging from completely disagree to completely agree. Because

this assessment does not specify the occupations, it may also overcome cultural

differences. The OBQ has good internal consistency, no floor or ceiling effects, all items

were stable and had a kappa coefficient below 0.60 and test-retest reliability was

sufficiently stable as well (Wagman & Hakansson, 2014).

The Occupational Balance-Questionnaire (OB-Quest) by Dürr, et al. (2014) is a self-

report instrument that consist of ten questions regarding occupational balance. Eight

components of occupational balance were used as a basis for the questionnaire. Each

question has three possible answers and the scores range between one and three.

Researchers found a good internal consistency, but they claimed that occupational

balance might be a multidimensional construct that is hard to capture within one

assessment.

The Meaningful Activity Wants and Needs Assessment (MANWA) from Eakman (2015)

consists of 21 items and taps a need for meaningful occupations. It proposes a new

definition of life balance so that persons can evaluate their ongoing occupations as

meaningful although they are currently not perceiving a need for more meaning in their

occupations. When a person is balanced, he or she will experience higher levels of

meaningful occupations and lower levels of perceived need for meaningful occupations.

The items from the MANWA are created upon items from validated measures of related

constructs such as meaningful occupation and occupational value. The assessment should

24

be capable of generating a score that reflects a person’s perceived need for meaningful

occupation. The MANWA shows very good internal consistency and test-retest

reliability, discriminant and convergent validity have been identified through its

correlation with both meaningful activity and indicators of well-being.

1.4 Multiple sclerosis, stress and well-being

Multiple sclerosis is an autoimmune demyelating disease of the central nervous system,

characterized by inflammation. The origin is unknown and it has an unpredictable course.

It is a progressive disease with a relapsing-remitting pattern (Casetta & Graniere, 2000).

The immune system attacks the brain and spinal cord causing lesions, this lesions can

either be silent or may cause a neurological deficit (Rapaport & Karceski, 2012). The

treatment of MS is mainly focused on the reduction of relapses, symptom and disability

relief (Artemiadis et al., 2012; Bruck, 2000; Karagkouni, Alevizos & Theoharides, 2013).

There is a well-established relationship between stress and MS. Stressors lead to

symptoms of anxiety and depression and this compromises their quality of life

(Artemiadis et al., 2012). Emotional stress can be linked with the exacerbation of

neurological symptoms (Artemiadis et al. 2011; Heesen et al., 2007). Studies show that a

long exposure to challenging life events is correlated with worsening neurological

symptoms and an increased number of lesions (Lovera & Reza, 2013; Mitsonis, Potages,

Zervas & Sfagos, 2009). Research suggests that reducing stress could help people with

MS to cope with and adjust to their disease (Artemiadis et al., 2012).

Compared to other chronic diseases, MS is considered as the most threatening to

psychological well-being (Bassi et al., 2014; Rudick, Miller, Clough, Gragg & Farmer,

1992), they experience a rather low well-being and high ill-being (Bassi et al., 2014).

Evidence suggests that people with MS are more sedentary than the general population

and that there is a positive effect on their well-being when they engage in more physical

exercises (Mc Auley, Motl, Morris, Doerksen, Elavsky & Konopack, 2007). Patients who

experience cognitive changes have a greater disturbance in performing activities of daily

25

living and are less likely to engage in social activities. This has an impact on their well-

being in general (Hakim, Bakheit, Bryant, Roberts, McIntosh, Spackman et al., 2000;

Shevil & Finlayson, 2006). Between 70 and 90 percent of the people with MS report

fatigue as one of the most annoying symptoms of MS (Béthoux, 2006). The fatigues has

a major impact on their lives and most of the people who experience fatigue conduct less

activities which results in less quality of life (Amato, Ponziani, Rossi, Liedl, Stefanile &

Rossi, 2001; Janardhan & Bakshi,2002). Fatigue has also been linked to depression,

Kroencke et al. (2003) suggested that depression and fatigue were highly correlated.

Research suggests that when people with MS engage in meaningful leisure pursuits, their

general satisfaction with life is increased (Hakim et al., 2000). Reynolds and Prior (2003)

state that taking care of their health, maintaining meaningful occupations and roles,

establishing mutual relationships, clarifying beliefs and valuing positive life experiences,

increased the quality of life of women with MS.

As described above, life balance is a construct with no consensus but is one of the core

concepts of occupational science. There are also not many assessment instruments

available to measure balance within the patient populations. None of the little amount of

assessments that is available is translated into the Flemish/Dutch language. It can be a

giant step forward for occupational therapists to have an instrument that measures balance

and use it within the field of the occupational therapy practice in Flanders. That’s why

there has been chosen to translate the LBI. People with MS are a good population to verify

the LBI because a lot of people with MS experience fatigue and can conduct less activities

of daily life which result in less quality of life (Amato, Ponziani, Rossi, Liedl, Stefanile

& Rossi, 2001; Janardhan & Bakshi,2002). Life balance is negatively related with stress

and positively related with well-being and health (Matuska, 2012b). Thus, when people

with MS can achieve higher levels of Life Balance, there is assumed that their stress level

will be decreased and they will experience more well-being and have a greater health

sense (Matuska & Christiansen, 2008). Using the LBI could help occupational therapists

in their practice with people with MS (Matuska & Christiansen, 2008).

See appendix 1 for the search strategy of this review of the literature.

27

2. Research question

As described in the introduction, there is no consensus regarding life balance and not

many assessment instruments are available. There are no instrument that measure the

construct of life balance in Flemish and so there has been chosen to translate the LBI.

Before using the LBI in our daily practice, the assessment has to be tested to make sure

the measurement measures the construct of life balance. There is some empirical evidence

about life balance and people with MS and there’s also evidence about the related

concepts of the LBM and LBI like well-being, stress and need-satisfaction by people with

MS. Because of this, there has been chosen to test the LBI by people with MS.

Following research question is proposed:

‘Is the Life Balance Inventory (Flemish version) a valid and reliable instrument to

measure the construct of life balance in people with multiple sclerosis who live at home?’

Following sub questions (and hypotheses) are proposed:

Do the overall scores of LBI, after waiting for at least one week, have the same

results as the first time?

Do all the subscales of the LBI have the same result, after waiting for at least on

week, as the first time?

Do all the items of the LBI contribute equally to the whole?

Does overall congruence (total score on the LBI) relate to less stress, higher well-

being, and higher need satisfaction?

Do the scores of each subscale individually relate to less stress, higher well-being

and higher need satisfaction?

Is there a relation between the LBI-scores and the demographic data?

Is there a difference in the total score of the LBI within the different demographic

categories (gender, marital status, years of MS, work situation and education)?

29

3. Method

3.1 Translating process

Before starting the quantitative research, the LBI needed to be translated into the Flemish

language. The following steps are conducted as proposed by Kielhofner (2006):

Translating to the target language: All of the items of the LBI have been translated

into the Flemish language after discussing how to formulate each item.

Consensus: Six people who had nothing to do with the study have indicated what

their thoughts were on every item. After they gave their meaning, all the results

were compared to find a consensus. The item is adapted if necessary in case of

disagreement.

Independent retranslation: Another independent person have translated the

Flemish version of LBI back into English. This has been done to make sure that

the items were still the same as in the original version. After this, the retranslated

test was sent to the original author.

Revision (if needed): If needed, some items would have been adapted. No items

needed a revision so this step has not been conducted.

Validity and reliability: The last step of the process is this study, checking for

validity and reliability evidence.

3.2 Research design

This is a non-experimental, observational, cross-sectional design looking for relationships

among variables at a given moment in time. Within this quantitative research, the

following items will be measured:

Construct validity: Kielhofner (2006) states that when an instrument tries to

describe and/or evaluate the content and construct validity should be examined.

Due to the short period in which the study has to be finished, there has been chosen

to only examine the construct validity. Fawcett (2007) states that when there is no

golden standard, construct validity must be measured instead of criterion validity.

30

The validity will be measured by calculating relationships between the LBI and

other assessments.

Test-retest reliability: As stated in the translation process, both the validity and

the reliability have to be tested. When an instrument evaluates it is important that

the results or consistent over time (Fawcett, 2007).

Internal consistence: An instrument should be as short as possible but still have

the same result as a long version. Because of this the internal consistence should

be examined, to check whether all of the items contribute equally to the test. If

some items contribute less than others perhaps they can/should be removed

(Kielhofner, 2006).

Correlations between the demographic data and the LBI: these items do not

validate or test the reliability of the LBI. This is a secondary analysis to draw

further conclusion about whether some profiles experiences more are less balance

then others (Matuska, 2010; Matuska, 2013).

3.3 Sampling

The participants have been recruited in the National MS-centrum at Melsbroek, Belgium.

This is one of the largest hospitals in Belgium for people with MS and other neurological

diseases. People can have both residential care and non-residential care where they come

in at morning or noon, receive their therapy and go back home (MS-Centrum, 2015). The

people who visit the outpatient clinic are the ones that can tell what balance is, people

who have experienced disbalance but have found some kind of balance now, are the ones

that can describe what balance exactly is for them (Stamm, 2009).

3.4 Operationalization

At least 20 persons were necessary to conduct the research. Otherwise there wouldn’t be

enough power and so the study would have no value (Portney & Watkins, 2014). The

participants have been selected on the basis of the inclusion and exclusion criteria as

31

described below. One of the occupational therapists in the centre selected the people that

fit the profile to participate in the study and who were likely to participate.

The participants had to meet the following conditions (inclusion criteria):

Adults, 18 – 65 years old;

Diagnosed with multiple sclerosis;

Living at home: people who visit the centre for one to three times a week have the

possibility to link the assessment to their home situation.

In social hospitalization: those people don’t have a relapse, they come in to

unburden their caregivers or to put their treatment on point. Those people also

have the possibility to link the assessment to their home situation.

Participants who met one of the following conditions were excluded (exclusion criteria):

In hospitalization: people who have a (major) relapse their idea of life balance

will be influenced both by the disease and by the revalidation setting they are

currently living in. A stable situation is necessary for the test-retest reliability.

Cognitive impairments: people who have a score of less than three on Rao’s Brief

Repeatable Battery of Neuropsychological Tests (BRB-N) (Brooks, Borela &

Fragoso, 2011) are excluded because some cognitive capacity is necessary to

understand the items/questions of the assessments. This test is administered

standard in the MS-centre.

At the start of this study, 15 participants were approached. Expect for one, they were all

willing to participate. While testing the first 15 participants, others that fit the profile were

addressed to make sure that there were enough participants. Later on, seven more people

have participated in the study. This makes a total of 22 participants, which means that the

goal of 20 participants was reached. All the participants have been tested twice within

two or three weeks with a pause of at least one week to make sure that there were no

recall-biases but much longer wasn’t favourable as well because of the changeable

character of their disease (Fawcett, 2007).

32

3.5 Data-gathering

The data-gathering took place at the National MS-centre at Melsbroek. People have to be

in a stable position when testing the test-retest reliability, as pointed out in the review of

the literature, a relapse or worsening of their disease does affect their well-being, stress

level and need satisfaction which automatically has an influence on their balance

(Matuska & Erickson, 2008; Bassi et al., 2014).

Both of the times the participants had to fill in a list with personal information like

whether they are married or not, how long they have MS, how many children they have,

… This information can be used later on to establish a profile of the average participant.

They also had to indicate whether are not they have a preferential tariff, this means that

they have to pay less for their medical care because they don’t have the resources to pay

the full price. This question is asked to have a better view together with the employment

status, on the patients financial situation. The participants had to fill in the EQ-5D as well,

this is a five-question assessment instrument that helps people indicate how good or bad

their health and quality of life is. It measures: mobility, self-care, daily activities, pain

and depression, participants have the following possible answers: (1) no problems at all;

(2) moderate problems or (3) serious problems (Lamers, Stalmeier, McDonnell, Krabbe

& Busschbach, 2005). This instrument was used to measure if the participants had some

major health changes in the past week, when 3 or more items had changed in comparison

with the first testing, people were excluded from the study.

The first time when they filled in the LBI, the participants had to fill in other

measurements as well to check the construct-validity of the LBI. Those instruments were:

The Depression Anxiety Stress Scales (DASS-21) stress subscale: This instrument

is a rather short instrument that measures stress and has good psychometric

properties. It contains seven items about stress and the participants have to answer

whether or not the statements are: non-applicable, almost never applicable,

sometimes applicable or always applicable. This instrument has been translated

into Dutch and has been tested on internal consistence and validity (de Beurs, Van

Dyck, Marquenie, Lange & Blonk, 2011). The scores of this instrument are

33

normal distributed (Henry & Crawford, 2005). This instrument is used because it

is assumed that life balance correlates negatively with stress.

The Personal Well-Being Index-adult (PWI-A): This instrument measures the

quality of life and the well-being of a person. On a scale from zero to ten, people

have to indicate how satisfied they feel with several items, the results of this test

are normal distributed (International Wellbeing Group, 2013). This instrument is

also translated into Dutch and has been validated and tested for reliability (Van

Beuningen & De Jonge, 2011). This instrument is used because it is assumed that

life balance correlates positively with well-being.

The Basic Psychological Needs Scale (BPNS): This instrument measures the

extent to which people are satisfied with their autonomy, competence and their

relationships (Vlachopoulos & Michailidou, 2006). The scores of this instrument

are normal distributed (Chen, Van Assche, Vansteenkisten, Soenens & Beyers,

2014). Matuska (2012b) used this instrument to validate the LBI because this

instrument is based upon the Self Determination Theory of Deci & Ryan (2000).

There is no similar instrument in Dutch, this is a gap in the validation of the LBI.

For further research, the BPNS has been translated into Flemish but has not been

validated or tested on reliability. This instrument is used because it is assumed

that life balance correlates positively with need-satisfaction.

3.6 Data-analysis

The data-analysis started with entering all the results into an Excel-file. Both the total

scores as the mean scores were calculated, on person-level as well as on group-level.

Means, standard deviations, ranges, … were calculated to compare the results from to

participants.

After entering the data on to the computer the statistical processing started. This has been

done on the basis of SPSS with a significance level of p = 0,05. The process has been led

on the basis of the hypotheses proposed in section of the research question.

34

The following actions have been conducted:

Test-retest reliability: The difference between the first and second testing has been

measured. First the correlation between the first and second testing has been tested

by the Pearson Product-Moment Correlation coefficient (Portney & Watkins,

2014). Yet this isn’t the most reliable method because this cannot detect

systematic error (Weir, 2005; McGraw & Wong, 1996). To make sure that no

systematic or random error interfered in the result, the intra-class correlation

(ICC) (and concomitant ANOVA) have been conducted using a two-way random

model and type consistency. This was chosen because it detects both the

systematic and random error. In this model the rater and subject are random

effects, it is assumed that the results can be generalized (Portney & Watkins,

2015). A score of 0,70 or more on the ICC indicates a good test-retest reliability

(Terwee et al., 2007).

Internal consistence: By using Cronbach’s alpha there has been measured if all

the items contributed equally to the test. Terwee et al. (2007) state that in order to

have a good internal consistence, the minimal score should be at least 0,70.

Construct validity and overall congruence: Correlations have been calculated

between the LBI and the DASS-21, the BPNS and the PWI-A by using the Pearson

correlation coefficient. There have been tested parametric because the all the

assessments scores have a normal distribution. Each subscale of the LBI was

tested as well, the correlations between each subscale and the DASS-21, the BPNS

and the PWI-A were calculated by using the Pearson correlation coefficient.

Relationship between the overall LBI scores and the demographic data: To check

the difference between the gender, an independent t-test was conducted. This test

has been chosen because it calculates whether there is a difference between the

mean score of each group (Portney & Watkins, 2014). For the other variables,

one-way ANOVA’s have been conducted because the independent t-test can only

measure 2 groups and these categories had 3 or more groups. This test also

compares the mean score of each group and sees if there are significant differences

(Portney & Watkins, 2014).

35

3.7 Ethical considerations

All participants are fully informed about the study and the ethical considerations that go

along with it. They have had an information letter and had at least one week to think about

their participation in the study. They voluntarily agreed to participate and all the

participants of the study have signed a consent form. The information letter and the

consent form can be consulted in the appendix. The ethical commission of the National

MS-centrum Melsbroek has approved the study.

37

4. Results

4.1 General information / demographic data

A total of 22 participants participated in this study and all the testings were conducted in

the outpatient clinic of the National MS-centre Melsbroek. They should represent the

population of people with MS who live at home and are receiving ambulant therapy.

Approximately 64% of the participants were female and 36% were male and the mean

age was 56 years old (see table 1 for a full list of the characteristics).

Table 1: Demographic characteristics

Age:

18 – 30 years

31 – 50 years

51 – 65 years

Total:

N

1

4

17

22

%

4,5

18,2

77,3

100

Gender

Female

Male

Total:

N

14

8

22

%

63,6

36,4

100

Marital status

Single

Married

Divorced

Widowed

Total:

N

5

13

3

1

22

%

22,7

59,2

13,6

4,5

100

Preferential tariff

Yes

No

Total:

N

20

2

22

%

90,9

9,1

100

38

Number of children

0

1

2

3 or more

Total:

N

9

4

4

5

22

%

40,9

18,2

18,2

22,7

100

Number of children living with you:

0

1

2 or more

Total:

N

21

1

0

22

%

95,5

4,5

0,0

100

Employment status

Working

Disabled

Retired

Total:

N

1

18

3

22

%

4,5

81,9

13,6

100

Education level

Secondary education: 1st cycle

Secondary education 2nd or 3the cycle

Bachelor degree

Master degree

Total:

N

7

10

2

3

22

%

31,8

45,4

9,1

13,6

100

The overall scores on the life balance inventory ranged from 1,48 to 2,81 with a mean of

2,33 and had a standard deviation (SD) of 0,32. The health subscale had the highest mean

score of all the subscales (mean = 2,38). The lowest mean scores were derived from the

relationship and challenge subscales (mean = 2,32) (See table 2 for a full list of the

descriptives).

39

Table 2: List of descriptive

N Minimum Maximum Mean Standard

deviation

Scale

range

LBI 22 1,48 2,81 2,3323 0,32370 1 – 3

Health subscale 22 1,67 3,00 2,3805 0,36027 1 – 3

Identity subscale 22 1,33 3,00 2,3623 0,40081 1 – 3

Challenge

subscale

22 1,27 2,88 2,3200 0,44570 1 – 3

Relationship

subscale

22 1,33 2,83 2,3186 0,33194 1 – 3

PWI-A 22 17 76 54,409 12,9418 0 – 90

DASS21 22 1 20 6,318 4,6740 0 – 21

BPNS 22 79 123 105,091 12,9464 21 - 147

4.2 Reliability

4.2.1 Test-retest reliability

The correlation between the first and the second measurement was calculated using the

Pearson product-moment correlation coefficient. A significant correlation between the

two tests was found (r = 0,934) on a significance level of p = 0,01. All of the subscales

showed significant correlations as well (See table 3 for all the correlation coefficients).

Table 3: Correlation coefficients

Correlation

Coefficient

Significance

(2-tailed)

LBI 1 – LBI 2 0,934 0,000

Health 1 – Health 2 0,657 0,001

Identity 1 – Identity 2 0,646 0,001

Challenge 1 – Challenge 2 0,885 0,000

Relationship 1 – Relationship 2 0,781 0,000

40

Because the Pearson Product-Moment Correlation Coefficient can’t detect systematic

error, the intraclass correlation coefficient (ICC) was calculated using a two factor mixed

effects model and type consistency.

First, an analysis of variance (ANOVA) was calculated to see if there were no differences

between the two trials. There was no difference between the first and second test moment

(F(1,21) = 0,739, p = 0,40). A high degree of consistency was found between the both

tests, the single measure ICC was 0,904 (p < 0,05) with a 95% confidence interval from

0,784 – 0,959.

These tests (ANOVA and ICC) have also been conducted onto all of the subscales from

the Life Balance Inventory. No differences between the two trials were found in all of the

four subscales. The health and identity subscale had a moderate degree of reliability (ICC

= 0,641 & ICC = 0,642), the relationship and challenge subscale had a high degree of

reliability (ICC = 0,710 & ICC = 0,881) (See table 5 for the ICC test results).

Table 4: ICC test results

Intraclass

correlation

(single

measure)

95% Confidence Interval F Test

Lower Bound Upper Bound Significance

LBI 1 – LBI 2 0,904 0,784 0,959 0,000

Health 1 & 2 0,641 0,310 0,834 0,000

Identity 1 & 2 0,642 0,311 0,834 0,000

Challenge 1 & 2 0,881 0,735 0,949 0,000

Relationship 1 &2 0,710 0,420 0,869 0,000

41

4.2.2 Internal Consistence

The Cronbach’s alpha based on standardized items in this sample was 0,825 which is a

good Cronbach’s alpha (Portney & Watkins, 2014; Terwee et al., 2007). A second

analysis was conducted to see all of the Cronbach’s alpha scores if each of the items was

deleted, yet none of the items had a larger influence than 0,013 if they were deleted thus

no items should be deleted.

4.3 Construct validity

4.3.1 Correlation between the overall scores and the DASS-21, the PWI-A, and the

BPNS

For measuring the construct validity of the Life Balance Inventory, correlations between

the LBI and other assessment have been examined. The following results are derived from

the statistical calculations, see table 7 for a full list of the correlations:

The Life Balance Inventory has a significant high negative correlation with the

DASS-21 (r = -0,827, p = 0,000) meaning that when a person has an increased life

balance score, he or she reports less stress levels or visa-versa.

The Life Balance Inventory has a significant high positive correlation with the

PWI-A (r = 0,694, p = 0,000) meaning that with an increase in the life balance

score, well-being increases or visa-versa.

No significant correlations were found between the life balance inventory and the

BPNS on a significance level (p = 0,332) meaning that when a person has

increased life balance, he or she does not necessarily reports a higher need

satisfaction.

42

4.3.2 Correlations between the subscale scores and the DASS-21, the PWI-A and

the BPNS

Second, the correlations between each subscale and the DASS-21, PWI-A and the BPNS

were calculated to see if each subscale has an influence on health, well-being or need

satisfaction. The following results were derived from the analysis, see table 7 for a list of

all the correlations:

None of the subscale correlated significant with the Basic Psychological Needs

Scale meaning that when a person has a higher balance score on the health,

identity, challenge or relationship subscale, he or she does not necessarily

experience a higher need satisfaction.

The relationship subscale did not have a significant correlation with the PWI-A

(p = 0,087). All of the other subscales did correlate with the PWI-A and all of the

subscales correlated with the DASS-21 as well.

Table 5: List of correlations

DASS-21 PWI-A BPNS

Correlation

coefficient

Sign.

Level

(2-

tailed)

Correlation

coefficient

Sign.

Level

(2-

tailed)

Correlation

coefficient

Sign.

Level

(2-

tailed)

LBI -0,827 0,000 0,694 0,000 0,217 0,332

Health -0,447 0,037 0,430 0,046 0,098 0,664

Identity -0,797 0,000 0,667 0,001 0,268 0,228

Challenge -0,739 0,000 0,661 0,001 0,138 0,541

Relationship -0,707 0,000 0,374 0,087 0,224 0,316

DASS-21: Depression Anxiety Stress Scale 21

PWI-A: Personal Wellbeing Index-Adult

BPNS: Basic Psychological Needs Scale

43

4.4 Secondary analyses

A secondary analysis was performed to give some additional information about the

relationship between demographic and clinical data (gender, marital status, years of MS,

work situation, and education) and life balance. The results are listed below.

No significant difference within the LBI-scores was found between men and women (p =

0,486).

The relations between the other categories and the overall score on the Life Balance

Inventory were examined by using one-way ANOVA. A significant difference in variance

between the subcategories was found for the category ‘years of MS’ but the ANOVA-

results showed that there was no significant difference between the means. No significant

differences in the overall LBI score were found within the different categories of marital

status, years of MS, work situation and education (Table 8).

Table 6: Results of the Levene’s statistic and ANOVA

Levene

statistic

Significance ANOVA

significance

Marital status 1,057 0,368 0,932

Years of MS 3,816 0,043 0,932

Work situation 0,572 0,459 0,059

Education 2,092 0,137 0,531

45

5. Discussion

The test-retest reliability, internal consistence and construct validity of the Life Balance

Inventory were the primary focuses of this research. The results of the study gained

evidence for the test-retest reliability, internal consistence and construct validity for the

Flemish version of the LBI. In the following sections a critical approach towards the

results and methodology will be made.

5.1 General information/demographic data

People with MS indicate that each day is difficult because they always have to make

choices whether or not they will do an activity because of their fatigue (Matuska &

Erickson, 2008). Moreover, a more recent study of Wagman et al. (2013) showed that ill-

being is related to a lower overall score on the LBI. Despite of these findings, the overall

scores of the participants were rather high (mean score = 2,34). The mean scores on the

LBI and it subscales in study of Matuska (2010) ranged from 2,22 to 2,38 which are the

same results as this study however evidence suggest that people with MS experience less

health and well-being and more stress (Bassi et al., 2014; Rudick, Miller, Clough, Gragg

& Farmer, 1992 This may be explained by the results of Matuska and Erickson (2008) in

women with MS, showing that participants did not want to mix their identity with their

MS. They felt like they were more than just their disease and did not want to be defined

by it. The same study discovered that most of the participants were still interested in many

occupations but settled for an adaptation because they could not conduct the entire activity

as they did it in the past. One participant who was physically severely disabled and

therefore no longer able to garden herself, reported to engage in this meaningful activity

by accompanying her husband while he is working in the garden. Another study showed

that people who are not employed have lower perceived stress than the working ones

(Matuska, 2013). In the current study, 21 participants didn’t work, mostly because of their

impairments. A study by Matuska and Christiansen (2008) discovered that women with

MS make frequent changes to their life in order to achieve more life balance. These

findings maybe explain why the overall scores on the LBI were rather high.

46

The variation in age of the participants in this study was rather low: 77% of the

participants were between 51 and 65 years old, which makes the study methodological

less strong (Fawcett, 2007). We have tried to vary between ages as much as possible,

however the age category between 51 and 65 years old was highly representative of the

outpatient group of the rehabilitation centre in that period . One of the explanations might

be that the first symptoms of MS occur between the age of 20 and 40 years old, and in the

beginning the symptoms are mostly not very distinct or do not have a big influence on the

daily life of a patient (Healthline, 2015). The degenerating character of MS makes that

people lose their physical and cognitive functions gradually (Casetta & Graniere, 2009).

So in the beginning people don’t receive therapy one or more whole days a week but they

just receive therapy at home or because it is not that simple to come a whole day to the

centre in combination with a job. This study included 64% women and 36% men, which

is a representation of the MS population. The ratio of women with MS and men with MS

is 2:1 (Healthline, 2015).

The mean score of the relationship subscale was the lowest (mean = 2,3186). One

explanation might be that people who are ill try to find ways to bring more balance in

their lives by only putting energy into the relationships that are reciprocal or supportive

(Hakansson et al., 2010). Similarly, a study of Matuska & Erickson (2008) showed that

participants didn’t feel understood by their family and friends and they did not always

have energy left for their relationships and to keep up with everyone.

The challenge subscale had the second lowest mean score (mean = 2,3200). This may be

explained by the fact that people with MS don’t have much energy left after doing their

essential occupations so the challenging or rewarding activities are skipped (Matuska &

Erickson, 2008).

The health subscale had the highest mean score of all of the subscales (mean = 2,3805).

Research has shown that people with MS spend a large part of their day maintaining their

health, and to be able to do so they give up other activities (Matuska & Christiansen,

2008). So mostly people with MS are able to meet their needs on this subscale but have

too little time or energy left to do other activities, which can be one explanation why the

47

scores on the other subscales were lower. A more heterogenic group of MS-patients

compared to the healthy population could give some more information about this subject

and why the health subscale had such a high mean score.

5.2 Test-retest reliability

Fawcett (2007) state that the correlation between the first and second test moment should

be as high as possible for in order to have a good test-retest reliability. Terwee et al.

(2007) claim that the ICC should be at least 0,70 or higher to have a good test-retest

reliability. The correlation of the overall scores in this study was high (ICC = 0,904). This

suggests that the LBI has a very good test-retest reliability. This is in accordance with the

Life Balance Model, which states that life balance is sustainable and thus can be

maintained over the long term (Matuska & Christiansen, 2008). One of the possible

explanations if the instrument did not show good test-retest reliability could be that

balance is not as sustainable as the creators of the LBM and the LBI suggested. By

proving the test-retest reliability some validity evidence for the LBM is found as well.

The health subscale did have the lowest consistency between repeated measurements

(ICC = 0,641) but had still a good reliability. One explanation might be that managing

their health is a large part of their day for people with MS (Matuska & Erickson, 2008)

and small changes are detected more quickly than when a person does an activity only

once or twice a month (Matuska, 2012b).

5.3 Internal consistence

The internal consistency was good (α = 0,825), some items did contribute less (ex. items

9, 26, 30, 35, 45) and some contributed more (ex. items 10, 16, 17, 23, 27, 33, 34, 37, 40)

to the whole than others Yet deleting items is not favourable because life balance is

something personal and some activities are more general than others (Matuska, 2010).

And even if some items were deleted, it wouldn’t make that much difference (α = 0,813

48

– 0,838). Matuska (2012b) conducted two studies to test the psychometric properties of

the original LBI, she did also find a high Cronbach’s alpha (α = 0,89 – 0,97).

5.4 Construct validity

The construct validity of this instrument was measured by calculating correlations

between the LBI and other assessments that measure related concepts. Although there

should be a correlation, the correlation shouldn’t be too high because otherwise there

would be no difference between the LBI and the other test and they would measure the

same construct (Kielhofner, 2006; Matuska, 2010). The results showed significant

correlations between the LBI and the DASS-21 and the PWI-A ranging from -0,447 to -

0,827 and 0,430 to 0,694. This suggests that they are related but they don’t measure the

same construct. This can be confirmed by other research that suggest that there is a match

between the time people actually spend and the time they want to spend in activities and

health and well-being (Backman, 2004; Wilcock, Hall & Hambley, 1997). A more recent

study conducted by Matuska & Christiansen (2008) revealed that people with MS who

cannot engage in the activities they want to do or spend too much time on them,

experience a higher stress level.

The correlation between the LBI and the DASS-21 was the highest of them all (r = -

0,872). One possible explanation is that a balanced live is highly related to less stress,

more sleep and more physical activity. A study from Hakansson & Matuska (2011) with

women with a stress-related disorder showed that they became ill and imbalanced when

they felt an overload of stress and anxiety. A study of Matuska & Christiansen (2008)

showed that when people with MS had more stress, more symptoms of their disease would

occur. The people included in this current study had a well general health feeling resulting

in higher scores on the LBI and lower scores on the DASS-21.

The correlations between each subscale and the DASS-21 and the PWI-A are lower than

the correlations between the overall scores and the DASS-21 and the PWI-A. Some

subscales did have a higher impact on stress and others on well-being but they all

49

correlated in some way. This can be explained by the fact that all the subscales together

measure a construct that should relate to the constructs of other tests (Matuska 2010).

No significant relations were found between the LBI or any of the subscales and the

BPNS. This test was used because the LBM and LBI are created upon the self-

determination theory, which state that people need a balance of activities that meet

different needs (Deci & Ryan, 2000; Reis, Sheldon, Gable, Roscoe & Ryan, 2002). To

date, there is no assessment in Belgium that measures this construct. Because of this, there

has been decided to translate the BPNS into the Flemish language without validity or

reliability evidence. It can be argued that due to the poor methodological quality of this

test, no correlations have been found. These findings are in contrast to Matuska (2012)

her results, she did find a correlation between both tests.

5.5 Secondary analyses

The secondary analyses showed no differences between the overall scores within the

different demographical categories. These findings are not consistent with the findings of

Matuska (2012b), which suggested that the number of children, the employment status

and gender did have an influence on the scores of the LBI. It is uncertain why these results

have not been found in our study but one logical explanation might be that the sample

size was to small (n = 22) in comparison with Matuska’s (n = 458), a larger sample size

would have had more statistical power and differences would have been easier to detect

(Portney & Watkins, 2014).

Matuska (2013) found a difference in overall scores between the age group from 18 to 50

years and the group from 61 to 100 years. There was no significant difference between

the group from 51 to 60 years and both the other groups. Although no significant

differences were found within the age categories, the results of the study of Matuska were

in line with the current study. The oldest group in the study of Matuska was almost not

included in the current study, none of the participants were 65 years or older. And no

difference was found between 18 and 60 years in the study of Matuska which could

explain why no differences were found in the current study.

50

Another significant difference in the study of Matuska (2013) was found between people

who were unemployed and the ones that worked or were going to school. Except for one

participant, none of the participants in the current study had a job or went to school. This

might be the reason why no significant difference was found between the groups in the

current study, the power and sample size were too small to detect the differences. Matuska

(2012b) found the same results in a previous study: non-working people have a higher

life balance than the ones that are working or go to school.

5.6 Methodology

Several statistical calculations were conducted while trying to confirm the hypotheses.

All of these did contribute to the validity and reliability evidence, yet some other

calculations could have been done. Matuska (2010) conducted a rash analysis to see if all

the items on the test contributed to a common construct. The core concept is that the

comparison of two people has no link with which items might have been used within the

set of items that assess the same variable (Tennant, McKenna & Hagell, 2004).

Moreover, Matuska (2010) conducted a factor analysis to evaluate whether all items

fitted correctly in a model.. These methods have not been used in this study because of

limited sample size (Mundfrom, Dale & Lu Ke (2005) stat that at least 100 participants

are needed to conduct a factor analysis) and resources, and could be done in future

research. The general conclusions that Matuska (2010, 2012a, 2012b, 2013) concluded in

her studies can be concluded as well in this study.

The sample size of this study was limited, resulting in reduced power (Fawcett, 2007;

Kielhofner, 2008). Nevertheless, most of the results reached statistical significance.

One of the difficulties of this study was the lack of normative data for the general

population in Flanders. The LBI has been validated for the general population in the

United States but it is uncertain whether these results can be generalized to the Flemish

population (Fawcett, 2007). This difficulty could easily be solved by gathering data from

the healthy population and convert it into norms.

51

The LBM suggests that there is always an environmental influence on life balance

(Matuska, 2012a). The methodology used in the current study has not taken into account

this influence and thus it cannot be claimed that the environment indeed has an influence.

Although there can be assumed that the environment has an influence because (almost)

all of the occupational therapy models speak of an environmental influence (AOTA,

2002; Chapparo & Ranka, 1997; Christiansen & Baum, 2005; Law et al., 1996; Polatajko,

Townsend & Craik, 2007), further research regarding this subject should be conducted to

gain further validity evidence for the LBI.

53

6. Recommendations for further research

The evidence found in this study could be used in further research and is an addition to

the small amount of research regarding life balance. It is particularly relevant for the

occupational therapy practice in Flanders and potentially The Netherlands because there

were no instruments in Dutch/Flemish that measured life balance. By translating,

validating and testing this instrument, occupational therapists can keep up with the

phenomenon of life balance and eventually may make it one of the core concepts of the

daily practice in OT. On the basis of this test the therapist can determine in which parts

in his or hers life parts the client experience balance or imbalance. This will help the

therapist in making client-centred goals and it will help conducting interventions focused

on increasing the balance in one’s life or redistribute the balance (one might have a score

of 2,25 on the LBI but only score 1,5 on the challenge subscale and score 3,0 on the health

subscale). Helping clients finding balance in their lives may potentially lead to lower

stress levels and higher senses of well-being. By looking at a list of many activities clients

may think of doing things that they have never done before or that they had forgotten

about. In collaboration with the occupational therapist, clients can explore alternative

ways to perform the activity (either or not using adaptations of equipment), which will

likely lead to an increased level of balance and an increased activity capital.

Although this study indicated some good results it is highly recommended to do further

research. The topics in the following paragraphs could be interesting for further research.

Future research should include more people, resulting in increased power and the ability

of researchers to use item response based methods (ex. Rasch analysis) or factor analyses

to further explore the construct validity.

Only the construct validity was tested in this study. Fawcett (2007) claims that when an

instrument tries to describe and evaluate, the content and construct validity should be

tested. It could be interesting to examine the content validity in the future to gain more

supporting evidence for the LBI and the LBM. The equivalence part of the LBI was not

tested in this study. To validate the LBI and the LBM, it is important to check whether or

54

not equivalence is an important part. No conclusive evidence has been found in other

research regarding this subject (Matuska, 2012b).

Evidence has been found regarding the LBI and people with MS but to make the validity

evidence stronger, the general population should be tested. This makes it possible to

compare the results and provide normative data. The validity and reliability of the LBI

should be tested in other patient populations as well (e.g. psychiatric patients or patients

with other physical diseases). The LBI has only been used and tested in a few countries,

almost no evidence is available from outside the United States or Sweden. To make it

possible to compare with other countries, more research should be conducted in versions

of other languages.

This study also didn’t determine whether the LBI has a good responsiveness or not.

Terwee et al. (2007, p37) define responsiveness as: ‘The ability of a questionnaire to

detect clinically important changes over time, even if these changes are small.’ When

conducting further research about interventions with the LBI or when the instrument is

used in daily practice, it is important that the instrument is able to detect changes because

otherwise there is no use in using the LBI.

A practical guide for therapists could be useful. When they use the LBI with their patients

they will receive a score between zero and three but this does not say which activities are

more difficult than others and which subscale scores are better or worse than the others.

There is no concrete plan for therapists to use the LBI and this can be a threat for the

therapist to use the LBI. It could be useful to see if an additional interview, list, … would

be necessary for getting a full image of the patients balance.

55

7. Conclusion

The main focus of this study was to determine the reliability and construct validity of the

Flemish version of the Life Balance Inventory that measures the construct of ‘life

balance’. In this study participated 22 non-residential patients of the outpatient

department of the MS-centre at Melsbroek. They completed the LBI twice and the first

time they had to fill in three other tests as well that measured related constructs of life

balance.

The results of this study showed good test-retest reliability of the overall scores and all of

the subscales. No conclusive evidence was found regarding the construct validity: there

is a relation between life balance and stress and well-being, however the expected relation

between life balance and basic psychological needs is lacking. Secondary analyses

showed no differences of the overall LBI-scores within the different demographical

categories.

These findings provide support for the validity and reliability of the Flemish version of

the LBI. It can help the occupational therapy practice in Flanders (and the Netherlands)

by using the concept of life balance, which can eventually be one of the core concepts of

the daily practice.

57

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Appendixes

69

Appendix 1: Search strategy review of literature

The following databases have been consulted in order to find evidence to write the

introduction and method:

LIMO, PubMed, Google Scolar, Trip Database, OT-seeker and Medline.

The following searchterms (Mesh-terms and general terms) were used in different

combinations:

Occupational therapy, occupational science, founders, history, occupational therapy

models, Canadian Model of Occupation Performance and Engagement (CMOP-E),

Person-Environment-Occupation model (PEO), Person-Environment-Occupational-

Performance model (PEOP), Matuska, Christiansen, Life Balance, Work-life balance,

Life Balance Model, Life Balance Inventory, Multiple Sclerosis, MS, other disciplines,

wellbeing, well-being, health, occupational balance, balance, lifestyle balance,

occupational integrity, flow, engagement, occupations, activities, Meyer, Person,

Environment, Royeen, Pierce, Stamm, performance, ill-being, differences, gender, Dutch,

Flemish, American Association of Occupational Therapy, prevalence, age, validity,

construct validity, content validity, internal consistence, reliability, test-retest reliability,

sample size, statistics, quantitative research, time-pressure, Western culture,

occupational perspective, perceptions, work, leisure, self-maintenance, sleep,

relationships, goals, internal values, depression, mood, anxiety, basic psychological

needs, meaningful, imbalance, Westhorp, Kielhofner, psychology, psychological

attributes, psychological, healthful, activity patterns, interaction, identity, assessment,

other, health experience, engagement, engage, meaningful occupations, core business,

Self-determination Theory, Deci & Ryan, Maslow, Ryff & Singer, Ryff, stress, satisfying,

meaning, meaningful, satisfaction, context, activity configurations, individual, groups,

evidence, research, social, men, women, construct, ratio, DASS-21, Depression Anxiety

Stress Scales-21, Personal Wellbeing Index Adult, Basic Psychological Needs Scale,

BPNS, PWI-A, correlation, psychometric properties, results, profile, Occupational

Balance Questionnaire, OBQ, Meaningful Activity Wants and Needs Assessment,

MANWA, instrument, cause, treatment, origin, quality of life, symptoms, cognitive

impairments, fatigue, secondary symptoms, activities of daily living, translating,

70

translating process, Nationaal MS-centrum Melsbroek, statistical calculation, design,

research design, power, RAO, BRB-N, Rao’s Brief Repeatable Battery of

Neuropsychological Tests, prognosis, ICF, bias, recall-bias, influence, demographic

questionnaire, demographic, EQ-5D, Nederlands, ethics, ethical considerations.

Further search has been conducted on the basis of the references of the different articles,

books, … Beside this, some of the basics of occupational therapy and occupational

science were used.

71

Appendix 2: Information letter

Informatiebrief voor deelname aan een wetenschappelijk onderzoek

Geachte mevrouw, mijnheer,

Via deze brief verzoeken wij u om medewerking aan een wetenschappelijk onderzoek. Dit

onderzoek wordt uitgevoerd in functie van een masterproef die kadert binnen de opleiding

Master in de Ergotherapeutische Wetenschap van de KU Leuven.

Onderstaande informatie kan u meer uitleg bieden en helpen te beslissen of u al dan niet aan

deze studie wenst deel te nemen. Indien u vragen of opmerkingen heeft, kan u zich steeds

richten tot de personen die onderaan deze brief vermeld staan. Wij raden u aan deze brief te

bewaren zodat u deze in de toekomst nog kan raadplegen.

Titel van het wetenschappelijk onderzoek:

Validatie- en betrouwbaarheidsstudie van de Life Balance Inventory

1. Doel

Met het huidige onderzoek willen we nagaan of de Life Balance Inventory een bruikbare test is

om life balance in kaart te brengen bij personen met MS. Life balance is het gevoel van balans

dat u als persoon ervaart. U voert dagelijks activiteiten uit, de ene activiteit vindt u al wat leuker

dan de andere. Voor uw welzijn is het belangrijk dat u tevreden bent met de activiteiten die u

uitvoert en dat deze activiteiten voor u gezond, betekenisvol en van lange duur zijn.

Het doel van de Life Balance Inventory is om alle activiteiten in kaart te brengen die u doet,

graag zou doen en graag minder zou willen doen. Aan de hand van de resultaten kan er dan

72

gerichtere therapie aangeboden worden die uw welzijn kan verhogen door te focussen op de

activiteiten die u zelf belangrijk vindt.

2. Metingen en procedures

De gegevens zullen verzameld worden aan de hand van enkele vragenlijsten die u dient in te

vullen in het Nationaal Multiple Sclerose Center te Melsbroek. Het invullen van de testen zal

maximaal 1 uur duren, u kunt zelf kiezen of u alle vragenlijsten vlak na elkaar invult of dat u

enkele pauzes neemt.

Om te kijken of de test ook nog hetzelfde resultaat geeft na 1-2 weken vragen wij u om één van

de vragenlijsten, de Life Balance Inventory, opnieuw in te vullen na deze periode. Dit zal

ongeveer nog een half uur van uw tijd in beslag nemen.

De Lokale Ethische Commissie van het Nationaal Multiple Sclerose Centrum te Melsbroek, heeft

de studie goedgekeurd.

3. Wat mag u van ons verwachten

De vragenlijsten die u invult, zullen discreet verwerkt worden en zullen niet aan derden

worden doorgegeven, tenzij u dat wenst;

De onderzoeksresultaten zullen geen identificatiegegevens bevatten en dus anoniem

behandeld worden;

De resultaten van dit onderzoek zullen worden gepubliceerd in de masterproef en een

wetenschappelijke tijdschrift, de rapportering gebeurt steeds anoniem;

De verkregen informatie wordt enkel gebruikt in functie van het onderzoek. U kunt wel

uw resultaten verkrijgen voor persoonlijk gebruik en/of te delen met uw arts/therapeut.

4. Wat zijn uw rechten

U mag steeds vragen stellen in verband met het onderzoek aan de onderzoeker;

U neemt deel uit vrije wil;

U kan op elk moment in het onderzoek beslissen om uw deelname aan deze studie stop

te zetten, door dit aan de onderzoeker te melden. Deze stopzetting zal geen enkele

invloed hebben uw verdere behandeling binnen het centrum.

73

5. Risico’s

Er zijn geen risico’s verbonden aan dit onderzoek.

6. Vergoeding

Er is geen vergoeding voorzien voor deelname.

Indien gewenst kunnen de resultaten van de testen doorgegeven worden aan u en/of

de behandelende therapeuten in het centrum.

Contactgegevens onderzoekers:

Daphne Kos – 0496/10.78.49 – [email protected] of [email protected]

Sven Van Geel – 03/641.82.41 – [email protected]

Hélène Dirix – 0475/32.58.42 – [email protected]

Karen Verbeek – 02/597.86.93 (Dienst ergotherapie MS Centrum Melsbroek)

mailto:[email protected]

75

Appendix 3: Informed consent

INSTRUCTIES VOOR DE DEELNEMER: gelieve deze vragenlijst zelf in te vullen

1. Hebt u de informatiebrief gelezen? JA NEE

2. Hebt u de mogelijkheid gehad om vragen te stellen over de studie? JA NEE

3. Hebt u voldoende antwoorden gekregen op uw vragen? JA NEE

4. Hebt u genoeg informatie ontvangen over de studie? JA NEE

5. Begrijpt u dat u vrij bent om de studie stop te zetten: JA NEE

a. Op elk moment

b. Zonder verantwoording te moeten geven voor de stopzetting

c. Zonder dat dit uw verdere medische opvolging zal beïnvloeden

6. Gaat u akkoord om deel te nemen aan deze studie? JA NEE

7. Gaat u akkoord om gegevens verzameld tijdens deze studie op te nemen

in een gegevensbestand? JA NEE

De Lokale Ethisch Commissie van het Nationaal MS Centrum heeft de studie als ethisch

verantwoord goedgekeurd.

Ik heb deze tekst grondig gelezen, begrijp het verloop van het onderzoek en verbind me ertoe,

om op vrijwillige basis, aan het onderzoek deel te nemen.

Naam:………………………………………………………… Naam:…………………………………………………………

Voornaam:………………………………………………… Voornaam:…………………………………………………

Datum:................../….............../.................. Datum:................../….............../..................

Plaats:………………………………………………………. Plaats:……………………………………………………….

HANDTEKENING DEELNEMER: HANDTEKENING ONDERZOEKER:

Validatie- en betrouwbaarheidsstudie van de Life Balance

Inventory

77

Appendix 4: Life Balance Inventory (Flemish version)

INSTRUCTIES:

STAP 1: Geef aan of u de activiteit uitvoert of ze wil uitvoeren door JA of

NEE aan te duiden.

STAP 2: Voor de activiteiten waar u JA heeft aangeduid, dient u na te denken

hoeveel tijd u hier de afgelopen maand heeft ingestoken. Duid/scoor de

vergelijking aan tussen de tijd die u daadwerkelijk heeft gespendeerd en de

tijd die u er aan zou willen spenderen.

STAP 2: Voor de activiteiten waar u JA

heeft aangeduid. De hoeveelheid tijd die ik

spendeer aan deze activiteit is …

STAP 1: ALTIJD SOMS ONGEVEER SOMS ALTIJD

IK DOE deze activiteit MINDER MINDER JUIST MEER MEER

IK WIL deze activiteit doen dan ik wil/dan ik wil/voor mij/dan ik wil/dan ik wil

Ja Nee Zorg dragen voor persoonlijke

hygiëne en uzelf wassen

1 2 3 2 1

Ja Nee Zorg dragen voor uw uiterlijk 1 2 3 2 1

Ja Nee Zorg dragen voor voldoende slaap 1 2 3 2 1

Ja Nee Ontspannen/rusten 1 2 3 2 1

Ja Nee Zorgen voor regelmatige beweging 1 2 3 2 1

Ja Nee Voedzaam eten 1 2 3 2 1

Ja Nee Zorgen voor eigen

gezondheidsbehoeften

1 2 3 2 1

Ja Nee Geld beheren

(rekeningen/budget/investeringen)

1 2 3 2 1

Ja Nee Rijden 1 2 3 2 1

Ja Nee Gebruik maken van openbaar

vervoer

1 2 3 2 1

Ja Nee Tijd spenderen met familieleden 1 2 3 2 1

Ja Nee Tijd spenderen met partner 1 2 3 2 1

Ja Nee Tijd spenderen met vrienden 1 2 3 2 1

Ja Nee Zorg dragen voor kinderen of

familieleden

1 2 3 2 1

Ja Nee Sexueel actief zijn 1 2 3 2 1

Ja Nee Deelnemen aan groepen

(verenigingen, cursussen etc.)

1 2 3 2 1

Ja Nee Nieuwe mensen ontmoeten 1 2 3 2 1

78







Ja Nee Betaalde arbeid verrichten 1 2 3 2 1

Ja Nee Uzelf ontwikkelen in uw job 1 2 3 2 1

Ja Nee Sociale contacten hebben op

het werk

1 2 3 2 1

Ja Nee Deelnemen aan formele

religieuze activiteiten

1 2 3 2 1

Ja Nee Deelnemen aan festiviteiten,

feestdagen vieren

1 2 3 2 1

Ja Nee Deelnemen aan

mogelijkheden tot bijscholing

1 2 3 2 1

Ja Nee Deelnemen aan professionele

organisaties

1 2 3 2 1

Ja Nee Vrijwilligerswerk uitvoeren in

de gemeenschap

1 2 3 2 1

Ja Nee Deelnemen aan

georganiseerde sport

1 2 3 2 1

Ja Nee Buitenactiviteiten doen 1 2 3 2 1

Ja Nee Tuinieren 1 2 3 2 1

Ja Nee Genieten van de natuur 1 2 3 2 1

Ja Nee Plannen en organiseren van

evenementen

1 2 3 2 1

Ja Nee Decoreren en inrichten van

ruimtes

1 2 3 2 1

Ja Nee Koken 1 2 3 2 1

Ja Nee Huishoudelijk werk uitvoeren 1 2 3 2 1

Ja Nee Gaan winkelen 1 2 3 2 1

Ja Nee Huisdieren verzorgen 1 2 3 2 1

Ja Nee Naar restaurant/café gaan 1 2 3 2 1

Ja Nee Naar film, theater, sportieve

evenementen gaan

1 2 3 2 1

79







Ja Nee Hobby's uitvoeren 1 2 3 2 1

Ja Nee Muziek maken 1 2 3 2 1

Ja Nee Artistiek bezig zijn 1 2 3 2 1

Ja Nee Onderhouden of repareren van

materiaal

1 2 3 2 1

Ja Nee Naaien/naaldwerk 1 2 3 2 1

Ja Nee Lezen 1 2 3 2 1

Ja Nee Gebruik maken van computer,

laptop, tablet, smartphone

1 2 3 2 1

Ja Nee Reflecteren of mediteren 1 2 3 2 1

Ja Nee Dagboek bijhouden 1 2 3 2 1

Ja Nee Componeren, schrijven

(muziek, gedichten etc.)

1 2 3 2 1

Ja Nee Dansen, yoga etc. 1 2 3 2 1

Ja Nee Vaardigheidsspellen spelen 1 2 3 2 1

Ja Nee TV kijken 1 2 3 2 1

Ja Nee Begeleiden van anderen

(mentor)

1 2 3 2 1

Ja Nee Reizen (alle vorm van reizen) 1 2 3 2 1

Ja Nee Verhalen vertellen 1 2 3 2 1

81

Appendix 5: Demographical questionnaire

Beantwoord volgende vragen kort of kleur bij volgende vragen het bolletje

voor het antwoord, dat voor u van toepassing is, in:

1. Geboortedatum: …………………….

2. Geslacht:

o Man

o Vrouw

3. Burgerlijke stand:

o Alleenstaand

o Gehuwd

o Samenwonend

o Gescheiden

o Weduwe/weduwnaar

4. Aantal kinderen: …………………….

5. Aantal kinderen nog ten laste: …………………….

6. Hoelang heeft u al multiple sclerose:

o < 5 jaar

o 5 – 10 jaar

o 10 – 15 jaar

o 15 – 20 jaar

o > 20 jaar

7. Werksituatie:

o Werkend

o (tijdelijk) werkloos

o Werkzoekend

o Invalide

o Pensioen

o Student

o Ander: …………………….

82

8. Hoogst behaalde diploma:

o Lager onderwijs

o Lager middelbaar onderwijs

o Hoger middelbaar onderwijs

o Bachelor/graduaat

o Master/licentiaat

o Doctoraat

o Ander: …………………….

Kleur bij volgende vragen het bolletje voor de zin die het beste uw

gezondheidstoestand van vandaag weergeeft:

9. Mobiliteit:

o Ik heb geen problemen met me te verplaatsen

o Ik heb enige problemen met me te verplaatsen

o Ik heb zeer ernstige problemen met me te verplaatsen

10. Zelfzorg:

o Ik heb geen problemen om voor mezelf te zorgen

o Ik heb enige problemen om mezelf te wassen of aan te kleden

o Ik ben niet in staat mezelf te wassen of aan te kleden

11. Dagelijkse activiteiten (Bijvoorbeeld: werk, studie, huishouden, gezins- of

vrijetijdsactiviteiten):

o Ik heb geen problemen met mijn dagdagelijkse activiteiten

o Ik heb enige problemen met mijn dagdagelijkse activiteiten

o Ik ben niet in staat om mijn dagdagelijkse activiteiten uit te voeren

12. Pijn/klachten:

o Ik heb geen pijn of andere klachten

o Ik heb matige pijn of andere klachten

o Ik heb zeer ernstige pijn of andere klachten

13. Angst/depressie:

o Ik ben niet angstig of depressief

o Ik ben matig angstig of depressief

o Ik ben erg angstig of depressief

83

Appendix 6: DASS-21 (Flemish version)

INSTRUCTIES:

Geef voor ieder van onderstaande uitspraken aan in hoeverre de uitspraak

afgelopen week voor u van toepassing was door een antwoord aan te

kruisen. Er zijn geen goede of foute antwoorden. Besteed niet te veel tijd aan

iedere uitspraak, het gaat om uw eerste indruk.

VRAGEN:

1. Ik vond het moeilijk om mezelf te kalmeren:

o Helemaal niet of nooit van toepassing

o Een beetje of soms van toepassing

o Behoorlijk of vaak van toepassing

o Zeer zeker of meestal van toepassing

2. Ik had de neiging om overdreven te reageren op situaties:





3. Ik was erg opgefokt





4. Ik merkte dat ik erg onrustig was





84

5. Ik vond het moeilijk om me te ontspannen





6. Ik had volstrekt geen geduld met dingen die me hinderden bij iets dat ik wilde

doen





7. Ik merkte dat ik nogal licht geraakt was





85

Appendix 7: PWI-A (Flemish version)

INSTRUCTIES:

De volgende stellingen peilen naar hoe tevreden u zich voelt op een schaal

van 0 tot 10. 0 betekent dat u zich helemaal ontevreden voelt, 10 betekent

dat u zich helemaal tevreden voelt. Het midden van de schaal is 5, dit

betekent dat u zich neutraal voelt, niet tevreden maar ook niet ontevreden.

Helemaal Helemaal

ontevreden Neutraal tevreden

0 1 2 3 4 5 6 7 8 9 10

1 Hoe tevreden bent u met uw leven

in het algemeen?

0 1 2 3 4 5 6 7 8 9 10

2 Hoe tevreden bent u met uw

levensstandaard?

0 1 2 3 4 5 6 7 8 9 10


gezondheid?

0 1 2 3 4 5 6 7 8 9 10

4 Hoe tevreden bent u met wat u op

dit moment bereikt hebt in uw

leven?

0 1 2 3 4 5 6 7 8 9 10


persoonlijke relaties?

0 1 2 3 4 5 6 7 8 9 10


veiligheidsgevoel?

0 1 2 3 4 5 6 7 8 9 10

7 Hoe tevreden bent u met de mate

waarin u zich onderdeel van uw

gemeenschap voelt?

0 1 2 3 4 5 6 7 8 9 10


zekerheid voor de toekomst?

0 1 2 3 4 5 6 7 8 9 10


godsdienst of levensovertuiging?

0 1 2 3 4 5 6 7 8 9 10

87

Appendix 8: BPNS (Flemish version)

INSTRUCTIES:

Lees de volgende items erg aandachtig, denk na over hoe dit in uw leven is,

en omcirkel dan hoe waar dit is voor u. Gebruik volgende schaal:

Helemaal Beetje Helemaal

niet waar waar waar

1 2 3 4 5 6 7

1 Ik heb het gevoel dat ik vrij ben om zelf te

beslissen hoe ik mijn leven leid.

1 2 3 4 5 6 7

2 Ik heb de mensen waarmee ik in interactie ga

echt graag.

1 2 3 4 5 6 7

3 Soms voel ik me niet echt

competent/bekwaam.

1 2 3 4 5 6 7

4 Ik voel me onder druk gezet in mijn leven. 1 2 3 4 5 6 7

5 Mensen die ik ken, vertellen me dat ik goed ben

in wat ik doe.

1 2 3 4 5 6 7

6 Ik kom overeen met mensen met wie ik in

contact kom.

1 2 3 4 5 6 7

7 Ik ben vooral op mezelf en heb niet veel sociaal

contact.

1 2 3 4 5 6 7

8 In het algemeen voel ik me vrij om mijn ideeën

en opinies te verkondigen.

1 2 3 4 5 6 7

9 Ik beschouw de mensen waarmee ik regelmatig

contact heb als mijn vrienden.

1 2 3 4 5 6 7

10 Ik ben recent in staat geweest om interessante

nieuwe vaardigheden te leren.

1 2 3 4 5 6 7

11 In mijn dagelijks leven moet ik vaak doen wat

men mij zegt te doen.

1 2 3 4 5 6 7

12 De mensen in mijn leven geven om mij. 1 2 3 4 5 6 7

13 De meeste dagen haal ik een gevoel van

vervulling uit wat ik doe.

1 2 3 4 5 6 7

14 De mensen met wie ik dagelijks contact heb

nemen vaak mijn gevoelens in overweging.

1 2 3 4 5 6 7

15 Ik krijg niet veel kansen in mijn leven om te

tonen hoe capabel ik ben.

1 2 3 4 5 6 7

16 Er zijn niet veel mensen waar ik close mee ben. 1 2 3 4 5 6 7

17 Ik heb het gevoel dat ik ongeveer mezelf kan

zijn in dagelijkse situaties.

1 2 3 4 5 6 7

18 De mensen met wie ik veel contact heb lijken

me niet al te graag te hebben.

1 2 3 4 5 6 7

19 Ik voel me soms niet erg capabel. 1 2 3 4 5 6 7

88

20 Er zijn niet veel mogelijkheden voor mij om

voor mezelf te beslissen hoe ik de dingen wil

doen in mijn dagelijks leven.

1 2 3 4 5 6 7

21 Mensen zijn in het algemeen vrij vriendelijk

tegen mij.

1 2 3 4 5 6 7

MASTER IN DE ERGOTHERAPEUTISCHE WETENSCHAP · 2015-11-06 · Academiejaar 2014-2015 MASTER IN DE...

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