The British Journal of Occupational Therapy-2015-Dür-4-15

Critical Review
Definitions of occupational balance and their

coverage by instruments
The British Journal of Occupational

Therapy
2015, Vol. 78(1) 415
! The Author(s) 2014
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DOI: 10.1177/0308022614561235
bjo.sagepub.com
Mona Dur1, Julia Unger2, Michaela Stoffer3, Razvan Dragoi4,

Alexandra Kautzky-Willer5, Veronika Fialka-Moser6, Josef Smolen7 and
Tanja Stamm8
Abstract
Introduction: Occupational balance is an important and widely used concept in occupational therapy and occupational science.
There is, however, not one unified definition in use, but several different ones, and thus instruments that measure the concept in
research studies are diverse as well. Consequently, it is unclear how instruments and definitions correspond. The purpose of this
study was to examine the coverage of occupational balance definitions by occupational balance instruments.
Method: Within a mixed-methods design we conducted a qualitative and quantitative content analysis of definitions and items of
existing instruments. Definitions and items were extracted from articles identified in a systematic literature search. The extent of
congruence and coverage between definitions and instruments was examined.
Results: The definitions used in 47 articles were structured into 19 categories. The categories which were found in most definitions
were a balance of various occupational patterns and areas (42; 89%) and occupational accomplishment, performance, roles and
responsibilities (35; 75%); 20 instruments were explored. Together they covered 16 (84%) of the 19 categories.
Conclusion: Knowing which instruments cover which dimensions of occupational balance can support occupational therapists,
other health professionals and health researchers in their selection of an instrument to measure occupational balance.
Keywords
Occupational science, assessments, content analysis, outcome research, conceptualisation
Received: 4 February 2014; accepted: 7 July 2014
Introduction
Occupational balance is an important concept in occupational therapy and occupational science. Occupational
balance has been considered as crucial for health and wellbeing since the very beginning of occupational therapy
(Meyer, 1977; Rogers, 1984). Occupational therapists currently explore various concepts to get a comprehensive
picture of occupation, such as occupational balance
(Creek, 2010; Gutman and Schindler, 2007). In order to
identify patients needs for interventions that target occupational balance (AOTA, 2011), and to evaluate their
eects, occupational therapists need to know underlying
dimensions and how to measure them.
There is no single denition of occupational balance
(Anaby et al., 2010b). Most recently, occupational balance
was dened as subjective perception of having the right
amount and variation of occupations (Wagman et al.,
2012a). Furthermore, occupational balance is occasionally
used in relation to or synonymously with life balance, lifestyle balance or worklife balance (Matuska, 2012b;
Wagman et al., 2012b). Occupational therapists need a
tangible denition of occupational balance, which should
reect the concept as accurately as possible to contribute
to the comparability of studies on occupational balance.
Denitions of occupational balance have been explored in

existing literature. Two of these articles address the urgent
task not only to provide a concise denition of occupational
1
Lecturer and Researcher, Department of Health Sciences, IMC University of

Applied Sciences Krems, Austria; Lecturer, Researcher and PhD Candidate,
Medical University of Vienna, Vienna, Austria
2
Lecturer and Researcher, FH Joanneum, Bad Gleichenberg, Austria
3
Research Fellow and PhD Candidate, Department of Internal Medicine,
4
Assistant Professor, Department of Rehabilitation, Physical Medicine and
Rheumatology, Victor Babes University of Medicine and Pharmacy,
Romania
5
Head of Gender Medicine Unit, Deputy Head of Internal Medicine III,
6
Head of Department of Physical Medicine and Rehabilitation, Medical
University of Vienna, Vienna, Austria
7
Head of Department of Internal Medicine III, Medical University of Vienna,
Vienna, Austria
8
University of Applied Health Sciences, Austria
Corresponding author:
Tanja Stamm, Head of Research Group for Clinimetrics, Department of
Internal Medicine III, Division of Rheumatology, Medical University of
Vienna, Spitalgasse 23, A-1090 Vienna, Austria, and Head of Master
Degree Program Health Assisting Engineering, FH Campus Vienna,
Favoritenstrae 226, 1100 Vienna, Austria.
Email: tanja.stamm@meduniwien.ac.at
Downloaded from bjo.sagepub.com by guest on November 12, 2016
Dur et al.
balance, based on current literature, but also to explore the

history and variety of denitions for occupational balance
(Backman, 2004; Wagman et al., 2012a). For example,
Wagman et al. (2012a) used a concept analysis to clarify the
content of occupational balance denitions and nally gave a
concise denition. Furthermore, three perspectives were
found to be used in relation to occupational balance
(Wagman et al., 2012a). The results did not assign certain
articles to the identied concepts referring to occupational
balance. Furthermore, the frequency of their occurrence was
not reported. Additionally, the conceptualisation of balance
was explored previously (Reece et al., 2009; Wada et al., 2010;
Westhorp, 2003). Wada et al. (2010) examined dierent concepts and perspectives of balance, including occupational and
life balance (Wada et al., 2010). However, the conceptualisation of occupational and life balance was not described and
discussed extensively. Thus, these articles did not report data
that could be further used to explore the coverage of the definitions of occupational and/or life balance by existing instruments. Moreover, both articles did not provide a detailed
presentation of the dierent contents of the denitions with
a systematic illustration of the methods used and the results
extracted. From this point on the term instruments encompasses measurements, questionnaires and single items.
Numerous instruments are currently available that can be
used to assess occupational balance. Based on the dierent
existing denitions, instruments that measure the concept in
research studies are diverse as well. Consequently, it is
unclear how instruments and denitions correspond. If occupational therapists want to select an instrument to evaluate
their interventions, they need to know which dimensions are
or are not covered by an instrument and about their psychometric properties (Mokkink et al., 2010a, 2010b). The
psychometric properties of several instruments to measure
occupational balance have been discussed and critically
appraised elsewhere (Anaby et al., 2010b; Backman, 2001;
Bejerholm and Eklund, 2006a; Christiansen, 1996;
Hakansson et al., 2009). However, there is no content comparison of the existing instruments and the dimensions of
occupational balance covered by these instruments. Such an
overview would help clinicians and researchers to easily
select the appropriate instrument. Thus, we nd it is imperative to rst compare denitions currently used. In order to
add value to the currently existing gap of information about
occupational balance denitions and instruments, a systematic literature search and content analysis is needed.
The purpose of this study was to examine the coverage
of occupational balance denitions by occupational balance instruments. Therefore, we aimed to (a) identify existing occupational balance denitions and instruments that
were developed and/or used to measure occupational balance, (b) examine their contents and (c) explore which
instruments cover those denitions.
Methods
Within a mixed-methods design we conducted a qualitative and quantitative content analysis (Creswell, 2003) separately, of denitions and items of existing instruments.
Denitions and items were extracted from articles identied in a systematic literature search. The extent of congruence and coverage between denitions and instruments
was examined.
Systematic literature search

In the rst step, a systematic literature search was conducted to identify articles on and denitions of occupational balance and life balance, as well as instruments
that were developed or used to measure these concepts.
The search was done in 2013 using PubMed, CINAHL
and Web of Science.
To be eligible for review, an article needed to meet the
following inclusion criteria: titles and abstracts containing
the keywords occupational balance or life balance; an
explicit denition of occupational and/or life balance or
description of an instrument used to measure occupational
and/or life balance; published in English in a peer-reviewed
scientic journal; and had at least one author who was an
occupational therapist. The latter criterion was established
to nd articles relevant to occupational therapy, and to
avoid the identication of articles that refer to occupation
as paid work exclusively. Additionally, articles referring to
postural or physical balance, or related balance disorders were excluded due to irrelevance. Life balance was
used as a keyword because some authors refer to this term
as occupational balance synonymously (Matuska, 2012b;
Wagman et al., 2012b). However, in order to provide information about which articles were identied by the search on
which term (occupational or life balance) and which categories have been used in relation to which concept, the
results were presented separately. Articles referring to balance of occupations, worklife balance, lifestyle balance
and a balanced life were included. Year of publication was
not a criterion for inclusion of an article.
Once candidate articles were identied, they were independently reviewed by three researchers (MD, JU and
Alexa Binder [AB]) through the use of a data extraction
form to extract occupational and/or life balance denitions
and occupational or life balance instruments. The team
members veried the accuracy of data extraction by concurrence. The selected articles were read mindfully by the
three researchers. All sections (abstract, introduction, methods, results, discussion and conclusions) were screened for
text sequences referring to occupational and/or life balance. Those denitions that were identied by the three
researchers were selected. In case of disagreement, discussion
led to a shared decision and the selection or exclusion of a
text sequence. Subsequently, the content of these text
sequences on occupational and/or life balance was listed
and used for further analysis. Similarly, a data extraction
form was used to identify instruments measuring one or
more aspects of occupational and/or life balance. To be eligible, an instrument needed to have a stated purpose to be
developed or used as measurement of occupational and/or
life balance, identied by two researchers (MD and JU). In
case of disagreement, a third researcher (AB) made a decision regarding the selection or exclusion of an instrument.
The British Journal of Occupational Therapy 78(1)
Since it was not the aim of this project, we did not consider
other psychometric properties of the instruments. If the
items of an instrument were not specied in the article they
were extracted from the original source.
Qualitative content analysis

Both occupational and life balance denitions, as well as
instruments items, were then listed and thematically clustered by the use of meaning categorisation, a qualitative
content analysis, as described by Kvale (1996). First, these
lists were reduced by the creation of sub-categories, thus
condensing the meaning of the original denitions or instrument items. Second, overlapping categories were combined
(details are explained in the example at the results section).
The meaning of the selected denitions and items was
explored and categorised by two authors independently (definitions: AB and MD; instruments: MD and JU). The identied categories did not have to be mutually exclusive, based
on their occurrence in the text sequences referring to occupational and/or life balance. Items that did not result in the
same interpretation by both analysts were discussed. In addition to this exchange, a third occupational therapist, not
involved in the previous analysis (Stefanie Haider), was
asked to mediate this process and come to a decision. This
process was completed and documented in Excel les. The
identied categories within the selected articles, as well as the
categories identied in the instruments, were summarised.
One item could encompass more than one category. Below
we provide an example of the analysis in which sub-categories and categories were created based on a specic
quote. In Eklund et al. (2009b), occupational balance is
dened as a balance between work, rest and play measured
in time. Based on this quote, the following two sub-categories were created: a balance of work, rest and play and a
balance of time used for work, rest and play. Out of the
nal categories (after combining overlapping sub-categories)
the following two were reassigned to this quote: a balance of
various occupational patterns and areas and of time spent,
time use, time pressure, pace and/or rhythm.
Quantitative content analysis

Furthermore, we conducted a quantitative content analysis
and used descriptive statistics to explore the frequency of
the identied categories and the extent of their coverage by
the instruments. The number of articles per identied category was calculated. Categories mentioned only in a maximum of three articles (1.3%) were not considered for
further investigation. Additionally, categories identied in
more than two-thirds (>66%) of the articles were dened as
the core dimensions of occupational and life balance.
In the nal step, the researchers matched instruments to
denitions in order to report how many instruments were
available to assess each category of occupational and life
balance denitions and to note denitions for which no
instrument existed. This study was part of a larger study,
namely the gender, occupational balance and immunology
(GOBI) study (Dur et al., 2014a).
Results
Selected articles
The literature search resulted in a total of 517 results, 16
on occupational balance in PubMed, 43 in CINAHL and
18 in Web of Science. The literature search on life balance
brought 263 results in PubMed, 43 in CINAHL and 134 in
Web of Science. Of these, 26 articles were duplicates and
were therefore removed; another 444 articles were
excluded due to their irrelevant contents. Finally, 47 articles were used for further analysis: 26 articles on occupational balance, 15 articles on life balance and six which
contained both occupational and life balance in the titles
and/or abstracts. Consequently, a total of 32 articles on OB
and a total of 21 articles on LB, of which six were the same,
were used for further analyses. Of the 47 articles, 13 provided information on the instrument items, while six additional articles were used to obtain instrument items. Thus,
a total of 19 articles were used for the extraction of instrument items. The articles selection process by the literature
search is shown in Appendix 1 (Moher et al., 2009).
In the tables, we referred to the specic articles and instruments thematically in an alphabetical order of the rst
authors names using the reference number of the articles,
as listed in Appendix 2.
We found 21 articles that described the use or development of 17 dierent occupational balance and two life
balance instruments, and one instrument (Q sort pack)
(Wagman et al., 2012b) that measured both occupational
and life balance. Half of the articles reported the use of
one instrument, eight articles described the use of two to
three instruments and one article referred to the use of
four dierent occupational balance instruments. The last
row of Table 1 represents the number of identied occupational and life balance instruments per article. In total,
20 instruments were described.
Identified categories
Definitions. We identied 96 sub-categories in the extracted
occupational and life balance denitions, which were nally
combined into a total of 19 categories (see Table 1, rst
column (columns articles; rows categories)). An example is the category equilibrium and congruence among
occupations. It contained the following sub-categories: satisfaction and dissatisfaction of occupations; congruence
between desired, ideal and actual occupational patterns; congruence and equivalence in activity conguration; equivalence in the degree of discrepancy between desired and
actual time spent across activities that meet dierent needs.
The following categories were identied as core
dimensions: a balance of various occupational patterns
and areas (42; 89%); occupational accomplishment, performance, roles and responsibilities (35; 75%); determinant of health (34; 72%); a balance of time spent, time use,
time pressure, pace and/or rhythm and capabilities and
challenges (both 33; 70%). The percentage of the numbers
of articles per category is presented in Appendix 3.
n OB/LB instruments
*strenuous and restful occupations
0
22
0
21
*time spent, time use, time pressure, pace and/or rhythm
*occupational identity, controllability and manageability
*various occupational patterns and areas
*occupational accomplishment, performance,

roles and responsibilities
*occupations (more/less) meaningful for the individual

and socio-cultural context
*harmony and conflict among occupations
*chosen and obligatory occupations
*capabilities and challenges
*caring for oneself and others
20
23
24
19
*social, physical and mental wellbeing
*abilities and restrictions to adapt occupations
Subjective and individual
Equilibrium and congruence among occupations
Engagement in meaningful occupations
Dynamic state and on-going process
Determinant of, or essential for, life satisfaction
Determinant of health
18
17
n OB/LB instruments
Biological need
*occupational accomplishment, performance, roles

and responsibilities
*occupations (more/less) meaningful for the individual

and socio-cultural context

References of articles on occupational balance
Biological need
Categories
Table 1. Identified categories per article.
25
26
10
27
11
1/1
28
12
30
1
29
14
13
32
16
(continued)
31
15
Dur et al.
7
39
41
42
43
44

0

0

0
45
46
47
OB: occupational balance; LB: life balance; : described in the definitions of OB; : described in the definitions of LB; : described in the definitions of OB and LB; *: A balance of . . .; (No.): reference of the article
found in the literature search on LB and OB; n: number.
n OB/LB instruments

1

0
*occupational accomplishment, performance, roles and responsibilities

*occupations (more/less) meaningful for the individual and

socio-cultural context

40
38

37
36

35

34

33
References of articles on life balance
Biological need
Categories
Table 1. Continued.
8
Dur et al.
Within the denitions of occupational and life balance,

the following categories were identied at an almost equal
frequency: determinant of health (occupational balance
24; 75% vs. life balance 16; 76%), occupational accomplishment, performance, roles and responsibilities (24; 75%
vs. 15; 71%), time spent, time use, time pressure, pace and/or
rhythm (20; 63% vs. 15; 71%), chosen and obligatory occupations (10; 31% vs. 5; 24%), capabilities and challenges
(22; 69% vs. 13; 62%) and subjective and individual (12;
38% vs. 7; 33%). Biological need was mentioned in relation
to occupational balance only. While life satisfaction was frequently quoted as being essential for life balance (6; 29%),
engagement in meaningful occupations was mainly related
to occupational balance (11; 34%). The categories aective
experience, a balance of doing and being, social demands
and life projects were not considered for further analysis,
since only three or fewer articles mentioned them. Five occupational balance articles used occupational balance synonymously with life balance (16%) and 12 did so with
lifestyle balance (38%). More articles reported the development or use of occupational balance instruments (18; 56%)
than life balance instruments (7; 33%), as shown in Table 1.
Instruments. In the 20 occupational and life balance instruments, we were able to identify a total of 65 categories.
The instruments consisted of 251 items which were used
for further investigation. The instruments characteristics
are briey described in Table 2.
Instruments coverage of the definitions

The instruments coverage of the denitions is depicted in
Table 3. Most often the instruments covered a balance in
various occupational patterns and areas (14; 70%), a balance of time spent, time use, time pressure, pace and/or
rhythm and equilibrium and congruence among occupations (both 12; 60%). Another frequently measured category was a balance of occupations (more and less)
meaningful for the individual and the socio-cultural context (11; 55%). Sixteen (84%) of the 19 categories that
were identied in the denitions were also covered by the
instruments. The Q sort pack (I-18) covered 13 categories
(68%). The time structure questionnaire (I-6, TSQ)
(Bond and Feather, 1988), the experiences of engagement
in patterns of daily occupations questionnaire (I-10)
(Hakansson et al., 2009), and the occupational value
instrument with predened items (I-17, OVal-pd)
(Eklund et al., 2003) covered eight categories each
(42%), which were also identied in the denitions.
Compared with their frequent use in articles, a balance
of occupational accomplishment, performance, roles and
responsibilities and capabilities and challenges were covered by few instruments (7; 35%, and 6; 30%, respectively). A balance of abilities and restrictions to adapt
occupations for example to changed life circumstances
was covered only once, by the Q sort pack (I-18). The
categories individuality and subjectivity and the dynamic
state of occupational or life balance were not covered by
the instruments (items). Nevertheless, the category
individuality and subjectivity is covered by some of the

instruments due to the fact that they assess patients perspectives. The health determining eect of occupational
and life balance was covered by two instruments:
Wilcocks Questionnaire on involvement in occupations
(I-14) (Wilcock, 1997) and the Q sort pack (I-18).
Discussion
To our knowledge, this is the rst study searching systematically for occupational and life balance instruments, and
exploring their coverage of existing denitions of occupational and life balance.
The results show that a balance of various occupational patterns and areas, as well as of occupational
accomplishment, performance, roles and responsibilities,
(89% and 75%, respectively) were the most frequent categories in the articles. The categories that were a balance of
various occupational patterns and areas and of time
spent, time use, time pressure, pace and/or rhythm were
the most frequent dimensions covered by the instruments
(70% and 60%, respectively). This may relate to the fact
that these two categories are easier to measure than other
complex dimensions of occupational balance (Eklund
et al., 2010). Time is fundamental to how people organise
and structure their daily lives, and can therefore be linked
closely to occupation (Edgelow and Krupa, 2011).
However, in two previous qualitative studies, a balanced
use of time was not found to be meaningful concerning
occupational balance for people with a chronic disease,
such as rheumatoid arthritis or Crohns disease (Dur
et al., 2014b; Stamm et al., 2009). Interestingly, the category balanced occupational accomplishment, performance, roles and responsibilities was found to be covered
by 35% of the instruments.
The category of biological need was only identied in
occupational balance articles. Moreover, in a recent qualitative study (Wagman et al., 2012b) occupational balance
has been found to be a part of life balance. In order to
guide occupational therapists in their understanding of the
two constructs, further studies on potential dierences or
similarities are suggested.
The health determining eect of occupational balance
has been reported frequently (Anaby et al., 2010a;
Backman, 2004; Sandqvist et al., 2005; Wilcock, 1997).
Surprisingly, even though occupational therapists are convinced that occupational balance has a positive eect on
health (identied in 23 occupational balance articles,
72%), it was found to be only measured by two instruments (Wilcocks Questionnaire on involvement in occupations [I-14] and the Q sort pack [I-18]). Nevertheless,
some of the studies included instruments that assess general health. In order to investigate this eect and a potential link between occupation and health, instruments that
assess general health should be used in addition to occupational balance instruments.
Another fundamental belief of occupational therapists
is that engagement in meaningful occupations is an essential part of occupational balance, as quoted frequently
10
Table 2. Characteristics of the identified instruments which were used, developed or suggested to measure occupational or life balance.
I-No. Name and content
I-1
I-2
I-3
I-4
I-5
I-6
I-7
I-8
I-9
I-10
I-11
I-12
I-13
I-14
I-15
I-16
I-17
I-18
I-19
I-20
No. Items
Personal project analysis: project elicitation list and cross impact matrix (CIM) (Anaby et al., 2010b) [OB]
13
Inter-goal relations questionnaire (IRQ) (Anaby et al., 2010b), [OB]
5
Satisfaction with balance of time spent on occupational areas and patterns (Backman et al., 2004) [OB]
1
Instrument of occupational balance (Bejerholm, 2010) [OB]
3
Profiles of occupational engagement for people with schizophrenia (POES) (Bejerholm and Eklund, 2006b) [OB]
9
Time structure questionnaire (TSQ) (Bond and Feather, 1988) [OB]
26
Satisfaction with daily occupations (SDO) instrument (Eklund, 2004) [OB]
9
Yesterday diaries on temporal occupational patterns of the last 24 hours (Eklund et al., 2010) [OB]
4
Three dimensions of occupational balance (Forhan and Backman, 2010) [OB]
3
Experiences of engagement in patterns of daily occupations questionnaire (Hakansson et al., 2009) [OB]
8
Occupational balance item (also contained in the experiences of engagement in patterns of daily occupations questionnaire)
1
(Hakansson et al., 2011) [OB]
Occupational questionnaire (Smith et al., 1986) [OB]
4
Possible measures of occupational balance (Wagman et al., 2012a) [OB]
15
Two-pages questionnaire on involvement in physical, mental, social and rest occupations (Wilcock, 1997) [OB]
6
Occupation, whats in it for me? (Wilson and Wilcock, 2005) [OB]
1/n.d.
Experience sampling methodology (ESM) (Csikszentmihalyi and Larson, 1987) [OB]
1/8
Occupational value instrument with predefined items (OVal-pd) (Eklund et al., 2003, 2009a) [OB]
26
Q sort pack (Wagman et al., 2012b) [OB, LB]
42
Meaningful activities and needs instrument (MAWNA) (Eakman, 2013) [LB]
21
Life balance inventory (LBI) (Matuska, 2012a) [LB]
53
I-No.: allocated number of the instrument; []: instrument was used or developed to assess occupational balance [OB] and/or life balance [LB],
respectively; n.d.: not described.
Table 3. Categories identified in the definitions of occupational and/or life balance covered by instruments to measure occupational and/
or life balance.
Instrument number (see Table 2)
Categories of OB and LB definitions
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Biological need
Determinant of healthy
Equilibrium and congruence among occupationsy
*capabilities and challengesy
*occupations (more/less) meaningful for the individual and the
socio-cultural contexty
*occupational accomplishment, performance, roles and responsibilitiesy
*various occupational patterns and areasy
*time spent, time use, time pressure, pace and/or rhythmy
*: A balance of . . .; OB: occupational balance; LB: life balance; : core dimensions, indicating that these categories were identified in more than
two thirds of the articles; : category is covered by the specific instrument.
Dur et al.
11
(34% of the articles) (Backman, 2004; Bejerholm and

Eklund, 2007). This belief is reected by three instruments
which were found to assess engagement in meaningful
occupations (Proles of occupational engagement for
people with schizophrenia [POES, I-5, Bejerholm and
Eklund, 2006b], Experiences of engagement in patterns
of daily occupations questionnaire [I-10] and Wilcocks
Questionnaire on involvement in occupations [I-14]).
Additionally, another related category, a balance of occupations (more and less) meaningful for the individual and
for the socio-cultural context, was found to be covered by
11 instruments (55%). This category could be a complementary issue to the measurement of engagement in meaningful occupations.
In our study, we identied a gap between the denitions
and instruments of occupational and life balance. For
example, the dynamic state of occupational balance is not
covered by any instrument. Furthermore, there are several
categories which are frequently cited, but seldom assessed,
such as occupational balance as determinant of health
(72% of the articles, measured by 10% of the instruments)
or of a balance of capabilities and challenges (70% of the
articles, measured by 30% of the instruments).
Wada et al. (2010) characterised balance with quantity,
congruence, fullment and compatibility. Wagman et al.
(2012a) found that occupational balance was related to
occupational areas, occupational characteristics and time
use. However, in the current study, the content of the definitions of occupational and life balance were categorised
in smaller units. This enabled the assignment of certain
articles to certain categories used in relation to occupational balance. Furthermore, the numerous categories
identied in the current project allowed a precise examination and statement on their coverage by existing occupational and/or life balance instruments. The numerous
categories identied in the current project allowed a precise examination and statement on their coverage by existing occupational and/or life balance instruments. Based on
the results of a systematic literature search, we were able to
give an overview about existing occupational and life balance instruments. Moreover, the ndings of this study can
support occupational therapists and other health professionals in their selection of instruments to assess occupational or life balance in practice and in research. An
example are patients with rheumatoid arthritis: activity
limitations and participation restrictions can result in a
loss of meaningful activities, such as engaging in sports
or attending social activities (Forhan and Backman,
2010). Thus, occupational therapy interventions that
improve functioning support the (re-) establishment of a
balance between dierent occupations, such as self-care,
productivity, leisure and rest. This could be assessed with
one of the occupational balance instruments that cover the
category that is a balance of various occupational patterns and areas. In addition, we suggest further research
to appraise other psychometric properties and thus complement the information that is important in assisting the
choice of an appropriate instrument. The TSQ (I-6), the
experiences of engagement in patterns of daily
occupations questionnaire (I-10) and the OVal-pd (I17) covered eight categories each. The Q sort pack (I18) covered 13 categories of the occupational and life balance denitions. Since instruments with few items are
more applicable for clinical use, we suggest the development of a brief occupational balance instrument based on
essential aspects important to patients.
Strengths and limitations

We included only articles published in peer-reviewed scientic journals. This could have limited the variety of the
dierent contents of the occupational and life balance definitions. Additionally, a search in dierent databases
could have led to other ndings and the identication of
more occupational and life balance instruments. However,
PubMed, CINAHL and Web of Science appeared to cover
most peer-reviewed scientic journals relevant to occupational therapists or occupational scientists. Additionally,
original sources upon which the used occupational and/or
life balance denitions were based were not obtained.
However, they were included for further analysis within
the selected articles. Another limitation was that we did
not search explicitly for occupational imbalance as a
related term. As it is unclear whether this is another
stand-alone concept or an aberration of occupational balance (Anaby et al., 2010a, 2010b), we decided not to look
specically for this keyword. The inclusion of the term life
balance seemed to be justied, since it is occasionally used
with regards to occupational balance in occupational therapy literature (Backman, 2004). The fact that the meaning
categorisation was conducted by researchers who are also
occupational therapists could have had an impact. The
inclusion of researchers with other professional backgrounds into this process may have led to dierent ndings. Moreover, the critical appraisal of current evidence
of instruments validities could have provided additional
important information. The detailed presentation of the
results increased the comprehensibility of the ndings.
Based on these ndings, the need for further research,
such as an analysis of the psychometric properties of the
identied occupational and life balance instruments,
becomes clear. Additionally, empirical data as well as
Delphi exercises could be used to nd consensus on the
denition of occupational balance.
Conclusion
The current denitions of occupational and life balance
used in scientic literature could be condensed to 19 categories, of which 16 are covered by 20 identied occupational and life balance instruments. Their examination can
support occupational therapists, other health professionals and health researchers to know which instruments
are already used or developed to measure occupational
balance. In addition, the ndings of this study can assist
these people in their selection of instruments when assessing the need for, or evaluating the eect of interventions
addressing, occupational balance.
12
Key findings
Denitions of occupational balance contained 19 categories. A total of 20 instruments were explored.
Together they covered 16 (84%) categories. The category
of a balance of various occupational patterns and areas
was covered most frequently.
What the study has added

This study provides an overview of the instruments that
measure occupational balance. Knowing which instruments cover which dimensions can support occupational
therapists to choose between occupational balance
instruments.
Acknowledgements
We would like to thank Alexa Binder for conducting the content analysis of the articles. Furthermore, we want to thank the native speakers
Andrea Jordan and Yvonne Schroder for proofreading, and Stefanie
Haider for the discussions on the meaning categorisation analysis.
Research ethics
Ethics approval was not required for this study.
Declaration of conflicting interest

None declared.
Funding
This research was partly funded by a restricted grant from the
Austrian Science Fund (FWF): [P21912-B09]. The FWF had no inuence on the content of the manuscript.
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Appendix 1. Flow diagram: article selection process based on a systematic literature search
Dur et al.
15
Appendix 2. Article numbers

No.
References of OB articles
No.
References of OB articles
No.
References of LB articles
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
(Anaby et al., 2010b)

(Backman, 2004)
(Backman et al., 2004)
(Bejerholm, 2010)
(Dubouloz et al., 2004)
(Dur et al., 2014a)
(Edgelow and Krupa, 2011)
(Eklund et al., 2009b)
(Eklund et al., 2010)
(Eriksson et al., 2010)
(Eriksson et al., 2011)
(Forhan and Backman, 2010)
(Gibbs and Klinger, 2011)
(Hakansson et al., 2009)
(Jonsson and Persson, 2006)
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Koome et al., 2012)

(Ludwig et al., 2007)
(McGuire et al., 2004)
(Morgan 2010)
(Ottenvall Hammar and Hakansson, 2013)
(Pettican and Prior, 2011)
(Sandqvist and Eklund, 2008)
(Stamm et al., 2004)
(Stamm et al., 2009)
(Wada and Beagan, 2006)
(Wagman et al., 2012a)
(Wagman et al., 2012b)
(Westhorp, 2003)
(Wilcock, 1997)
(Wilson and Wilcock, 2005)
(Argentzell et al., 2012)
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
(Eakman, 2013)
(Hakansson and Matuska, 2010)
(Johansson et al., 2012)
(Lisson et al., 2013)
(Majnemer, 2010)
(Matuska, 2012a)
(Matuska, 2012b)
(Matuska and Christiansen, 2008)
(Matuska et al., 2013)
(Pentland and McColl, 2008)
(Piskur et al., 2002)
(Reece et al., 2009)
(Wada et al., 2010)
(Wagman et al., 2011)
LB: life balance; No.: number; OB: occupational balance.
Appendix 3. Percentage of the numbers of articles describing a certain category

Percentage of articles
Categories of OB and LB definitions
All
OB
LB
Biological need
Determinant of healthy
Equilibrium and congruence among occupationsy
*capabilities and challengesy
*occupations (more/less) meaningful for the individual and the socio-cultural contexty
*occupational accomplishment, performance, roles and responsibilitiesy
*various occupational patterns and areasy
*time spent, time use, time pressure, pace and/or rhythmy
16
74
16
58
23
67
35
33
14
70
26
35
26
67
79
91
40
51
74
22
71
3
61
32
54
39
45
6
68
8
32
29
54
74
94
23
54
64
0
67
33
44
0
83
33
0
33
61
4
33
11
72
89
72
67
33
72
*: A balance of . . .; OB: occupational balance; LB: life balance; All: percentage of all articles; y: core dimensions, indicating that these categories
were identified in more than two-thirds of the articles.

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Critical Review

Definitions of occupational balance and their

The British Journal of Occupational

Mona Dur1, Julia Unger2, Michaela Stoffer3, Razvan Dragoi4,

Denitions of occupational balance have been explored in

Lecturer and Researcher, Department of Health Sciences, IMC University of

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balance, based on current literature, but also to explore the

Systematic literature search

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The British Journal of Occupational Therapy 78(1)

Qualitative content analysis

Quantitative content analysis

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Downloaded from bjo.sagepub.com by guest on November 12, 2016

*strenuous and restful occupations

*time spent, time use, time pressure, pace and/or rhythm

*occupational identity, controllability and manageability

*various occupational patterns and areas

*occupational accomplishment, performance,

*occupations (more/less) meaningful for the individual

*harmony and conflict among occupations

*chosen and obligatory occupations

*capabilities and challenges

*caring for oneself and others

*social, physical and mental wellbeing

*abilities and restrictions to adapt occupations

Subjective and individual

Equilibrium and congruence among occupations

Engagement in meaningful occupations

Dynamic state and on-going process

Determinant of, or essential for, life satisfaction

*time spent, time use, time pressure, pace and/or rhythm

*strenuous and restful occupations

*occupational identity, controllability and manageability

*occupational accomplishment, performance, roles

*various occupational patterns and areas

*occupations (more/less) meaningful for the individual

*chosen and obligatory occupations

*harmony and conflict among occupations

*caring for oneself and others

*capabilities and challenges

*social, physical and mental wellbeing

*abilities and restrictions to adapt occupations

Equilibrium and congruence among occupations

References of articles on occupational balance

Subjective and individual

Engagement in meaningful occupations

Dynamic state and on-going process

Determinant of, or essential for, life satisfaction

Table 1. Identified categories per article.

*time spent, time use, time pressure, pace and/or rhythm

*strenuous and restful occupations

*occupational identity, controllability and manageability

*various occupational patterns and areas

*occupational accomplishment, performance, roles and responsibilities

*occupations (more/less) meaningful for the individual and

*harmony and conflict among occupations

*chosen and obligatory occupations

*caring for oneself and others

*capabilities and challenges

*social, physical and mental wellbeing

References of articles on life balance

*abilities and restrictions to adapt occupations