Scandinavian Journal of Occupational Therapy

ISSN: 1103-8128 (Print) 1651-2014 (Online) Journal homepage: https://www.tandfonline.com/loi/iocc20

Construct validity of a revised version of the

Occupational Balance Questionnaire

Carita Håkansson, Petra Wagman & Peter Hagell

To cite this article: Carita Håkansson, Petra Wagman & Peter Hagell (2019): Construct validity
of a revised version of the Occupational Balance Questionnaire, Scandinavian Journal of
Occupational Therapy, DOI: 10.1080/11038128.2019.1660801

To link to this article: https://doi.org/10.1080/11038128.2019.1660801

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SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY
https://doi.org/10.1080/11038128.2019.1660801

ORIGINAL ARTICLE

Construct validity of a revised version of the Occupational Balance

Questionnaire
Carita Håkanssona , Petra Wagmanb and Peter Hagellc
a
Division of Occupational and Environmental Medicine, Lund University, Lund, Sweden; bDepartment of Rehabilitation, School of
Health and Welfare, J€onk€oping University, J€onk€oping, Sweden; cDepartment of Nursing and Integrated Health Sciences, Kristianstad
University, Kristianstad, Sweden

ABSTRACT ARTICLE HISTORY

Background: Occupational balance is fundamental to occupational therapy and occupational Received 3 May 2018
science. Therefore, the Occupational Balance Questionnaire (OBQ) was developed and has previ- Revised 13 August 2019
ously been found psychometrically valid according to classical test theory. Accepted 23 August 2019
Aim: To investigate the internal construct validity of the OBQ using Rasch measurement theory.
KEYWORDS
Material and methods: Data from two general population samples were used to investigate Measurement; occupational
the psychometric properties of the OBQ according to Rasch measurement theory. science; occupational
Results: The analyses identified problems with the current response scale and multidimensional- therapy; psychometrics
ity of two items. As a result, a revised version, the OBQ11, was suggested and exhibited
response categories that worked properly, good reliability (0.92), model fit and measurement
invariance across age and gender groups. The hierarchical item ordering was in agreement with
previous research.
Conclusion: The new OBQ11 satisfies the measurement criteria defined by the Rasch model.
However, further studies of additional samples are needed to validate its generic properties.
Significance: The purpose of the OBQ11 is to measure occupational balance of individuals or
groups, and to identify aspects of occupational balance in need of improvement. Our observa-
tions suggest that the OBQ11 is a valid and promising complement to other instruments.

Introduction month. Furthermore, balance is assessed as congruence

Occupational balance has been fundamental to occu-
pational therapy theory and practice ever since the
birth of the profession [1]. Occupational balance is
not focusing on balancing different occupations into
equal proportions or equilibrium. Rather it is a com-
plex concept and it is conceptualized and measured
in different ways, focusing on various aspects such as
need satisfaction [2–3], levels of meaningfulness [4],
and types of occupation [5], as described below.
Matuska [2] developed the Life Balance Inventory
(LBI) conceptualizing life balance, based on the life bal-
ance model [3] and defines it as ‘a satisfying pattern of
daily activity that is healthful, meaningful and sustain-
able to an individual within the context of his or her
current situation’ (p. 11). LBI consists of 53 predefined
activities and people rate how satisfied they are with
how much time they spent doing the activity in the last
and equivalence, where congruence means a match
between actual and desired activity configuration, and
equivalence means approximately equal apportioning of
time use across the four needs dimensions. Eakman [4]
developed the Meaningful Activity Wants and Needs
Assessment (MAWNA), and he defined life balance as
high levels of meaningful activity concurrently with low
needs for additional meaningful activity experiences [4].
MAWNA assesses the balance between actual and
desired engagement in meaningful occupations. D€ ur
et al. [5] developed the Occupational Balance
Questionnaire (OB-Quest) among people with auto-
immune diseases and healthy people. They found that
occupational balance includes the following compo-
nents: balance between different types of occupations,
between abilities and resources, and between one’s own
and others’ needs. Based on these components 10 items
were developed.

CONTACT Carita Håkansson carita.hakansson@med.lu.se Division of Occupational and Environmental Medicine, Lund University, Medicon Village,
Lund SE 223 81, Sweden
ß 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in
any way.
2 C. HÅKANSSON ET AL.

Table 1. The OBQ items (short form).

Item number Item
1 Having just enough to do during a regular week
2 Balance between doing things for others and for oneself
3 Perceiving one’s occupations as meaningful
4 Time for doing things wanted
5 Balance between work, home, family, leisure, rest, and sleep
6 Balance between doing things alone and with others
7 Have sufficient time for doing obligatory occupations
8 Balance between physical, social, mental, and restful occupations
9 Satisfaction with how time is spent in everyday life
10 Satisfaction with the number of activities during a regular week
11 Balance between obligatory and voluntary occupations
12 Balance between energy-giving and energy-taking activities
13 Satisfaction with time spent in rest, recovery, and sleep

However, another important aspect of occupational
balance, not yet addressed in a measurement is ‘the
experience of having the right amount of occupations
and the right variation between occupations in the
occupational pattern’ [6, p. 326] (regardless of what
the occupations are). Therefore, we developed the
Occupational Balance Questionnaire (OBQ) [7]. It
intends to be a generic instrument to evaluate occupa-
tional balance of individuals and groups. In occupa-
tional therapy a valid and reliable instrument to
measure this conceptualization of occupational bal-
ance is needed. The conceptual framework for the
OBQ is based on results from previous research on
the experience of occupational balance in different
groups [8–10], and a concept analysis of occupational
balance [6]. Types of indicators that are useful for
eliciting occupational balance were developed based
on these studies (potential item format). The 13 OBQ
items (Table 1) have six ordered response categories
with verbal descriptions and the participant rates his/
her level of agreement with different aspects of
amount of and variation between occupations in the
occupational pattern (0 ¼ completely disagree,
1 ¼ disagree a lot, 2 ¼ tend to disagree, 3 ¼ tend to
agree, 4 ¼ agree a lot, and 5 ¼ completely agree). Item
scores are summed into a total score that can range
from 0 to 65. A higher score means a higher occupa-
tional balance. The OBQ focuses on the variation in
the occupational pattern (between different types of
occupations, between doing things for oneself and for
others, between doing things alone and together with
others), the amount of each occupation and the total
amount of occupations (amount of, time for, number
of), and the perceived meaningfulness in the occupa-
tions. All these aspects are considered necessary for
the experience of occupational balance.
The OBQ was piloted using classical test theory
(CTT) to evaluate its psychometric properties [7].
Results showed good total score internal consistency
(Cronbach alpha, 0.94) and test-retest reliability
(Spearman’s Rho, 0.93) without any floor or ceiling
effects. Test-retest reliability of individual items varied
between 0.61–0.83.
However, CTT approaches to assessing the meas-
urement properties of scales have limitations [11–13].
For example, it rests on assumptions that cannot be
readily tested and is largely based on correlation anal-
yses, which has limited relevance to the concept of
measurement as understood in physical sciences as
well as in common language (e.g. in terms of com-
mon ruler) [12,13]. Additionally, CTT does not read-
ily allow for assessment of fundamental aspects of the
measurement process, such as whether response cate-
gories work as expected and whether the instrument
works in the same manner across different subsets of
respondents. To this end, the Rasch measurement
model [14] provides a powerful alternative by deter-
mining the extent to which observed data confirm
with the model [11–15]. The Rasch model is a general
unidimensional measurement model for latent varia-
bles that is based on the same principles as measure-
ments in physical sciences; the model states that the
probability of a certain item response depends on
the level of the measured construct represented by the
item and the person, respectively [16,17]. As such,
it provides a detailed account for the extent to
which item responses are productive in producing
objective measures at an interval level, as well as a
powerful diagnostic tool regarding any anomalies
that contradict objective measurement (e.g. whether
response categories work as intended and if items
are working the same way across respondent sub-
groups). Furthermore, the Rasch model determines
empirically how items (and persons) are ordered on a
latent continuum from less to more of the target vari-
able, which allows for an investigation of the coher-
ence between the instrument and its underpinning
theory [18,19]. As such, Rasch measurement theory
(RMT) provides a valuable and theoretically as well
as clinically appropriate tool in assessing the

measurement properties of rating scale based instru-
ments [11–15,18].
Aim
The aim of the present study was to investigate the
internal construct validity of the OBQ in a general
population using Rasch measurement theory.
Specifically, item fit, reliability, response categories,
differential item functioning and logical hierarchical
ordering of the items were assessed.
Material and methods
Participants
As this article reports a process, data collection was
conducted in two phases and included two samples
(Samples 1 and 2) from general populations in
Southern Sweden. They were selected through pur-
posive sampling. The authors and their students used
their network to identify presumptive participants,
and they received an information letter that invited
them to the study, detailing the aim and study design.
It also explained that it was voluntary to take part in
the study and that the participants could withdraw
from the study at any time without giving any explan-
ation. Finally, the letter explained that the participants
answered the OBQ anonymously and that no
unauthorized person would have access to the data.
An addressed return enveloped was also added. The
inclusion criteria were persons 20 years old and older
(as they are no longer in school) and the ability to
understand Swedish. A heterogeneous sample regard-
ing age and gender was the goal.
Data analyses
In this study, the OBQ was tested according to RMT
(12, 14, 15). Specifically, reliability, Rasch model fit,
rating scale response category functioning, uniform
and non-uniform Differential Item Functioning (DIF)
by gender and age (younger vs. older persons, as
defined by the median), targeting, and the logic of the
hierarchical item ordering were addressed. Reliability
was estimated using the Pearson Separation Index
(PSI), which is conceptually analogous to coefficient
alpha [20], and should preferably be at least 0.8 [12].
Fit between empirical data and the unidimensional
Rasch measurement model was examined from sev-
eral perspectives. Individual item fit residuals repre-
sent discrepancies between empirical responses and
model expectations and should range between about
SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 3
2.5 and 2.5, with the ideal being 0 [21]. Overall, the
mean standardized item and person fit residuals
should be close to 0 with a standard deviation close
to 1. Chi-square statistics test whether the difference
between the observed and expected values for each
item is statistically significant or not. In general, non-
significant Chi-square statistic supports fit to the
model. In addition, accordance between item response
data and model expectations was examined graphic-
ally by inspection of item characteristic curves (ICC).
Taken together, these analyses provide evidence of
potential anomalies between any particular item
which may over- or under discriminate relative to the
summary discrimination of all items [22]. Anomalies
may arise due to measurement problems such as local
response dependence, multidimensionality or poor
item quality, which may threaten validity [19]. Large
negative standardized fit residuals suggest over-dis-
criminating items and local response dependence,
whereas large positive residual values indicate under-
discriminating items and are typically due to local
trait dependence (i.e. multidimensionality) [12]. To
examine local dependency in greater detail, the rela-
tive correlations between standardized item residuals
were examined. In general, these correlations should
not exceed 0.2–0.25 [23,24].
The OBQ has response categories ranging from
low agreement to high agreement with the statements
in the questionnaire. Whether the OBQ response cat-
egories work as assumed was assessed by examining
response category thresholds [22]. A threshold is the
point where the probability of a response is the same
between two adjacent response categories. In the
event of disordered thresholds, response categories do
not work as intended.
DIF is an additional aspect of fit that concerns
whether items work the same way for different sub-
groups, for example different age groups or men and
women. Age was dichotomized into older
(50–89 years old) vs. younger (20–49 years old)
according to the median. Here we addressed uniform
(subgroup main effect) and non-uniformed (sub-
group  location interaction effect) DIF by 2-way
ANOVAs of residuals [25]. Items exhibiting DIF were
adjusted by splitting the item into two subgroup-spe-
cific items followed by examination of the impact of
DIF on the total score.
Targeting refers to the correspondence between
item and person locations, where person locations
along the measurement continuum preferably should
be mirrored by item locations, and vice versa, in
order to maximize precision in estimated person and
4 C. HÅKANSSON ET AL.
Table 2. Overall Rasch model fit statistics and reliability.
Sample 1. 13 items, 6
response categories
Item fit residuals
Meana 0.148
SDb 3.254
Person fit residuals
Meana 0.641
SDb 1.795
Total item-trait interaction
Total item Chi2 (df) 121.16 (39)
p-valuec <0.001
Reliabilityd
Person separation index 0.93
Targetinge
Person location, mean (SD) 1.331 (1.540)
a
Should be close to 0.
b
Should be close to 1.
c
Should be >0.05 to suggest model fit at all levels of balance and over all items.
d
Person Separation Index, should be > 0.8, relative to the mean item logit location (i.e. zero).
item measures as well as the conditions for scale
evaluation. Detecting differences between people is an
important function of measurement, which is linked
to measurement precision and, therefore, also to tar-
geting and reliability.
According to RMT, people with low occupational
balance are expected to have low probabilities to
endorse items expressing high levels of occupational
balance. As this is the basis of locating items (and
persons) on the latent logit continuum, it provides
the foundations for examining the nature of how the
construct varies as one moves from lower to higher
levels of occupational balance, and the extent to
which this is in accord with clinical and theoretical
experiences. The logic of the hierarchical ordering of
item locations was, therefore, considered as means to
assess internal content and construct validity.
Data were analyzed according to the unrestricted
polytomous (‘partial credit’) Rasch model using
RUMM2030 [26], and the program divided the sam-
ples into four class intervals (subgroups of people
with similar levels of occupational balance according
to total OBQ scores). Bonferroni adjustments for mul-
tiple null hypothesis testing were applied, with the
alpha level of significance set at 0.05 [27,28].
Results
Sample 1, (who responded to the original 13-item
version of the OBQ), consisted of 168 persons aged
21–64. The mean (SD) age was 53 (12) and 68 per
cent were women. The reliability of the OBQ was
good, and the overall fit to the model was reasonable
(Table 2). However, the response category thresholds
were disordered in four items (items 2, 4, 6 and 7). A
similar pattern (albeit marginally ordered) was also
Sample 2. 13 items, 4 Sample 2. 11 items, 4 response
response categories categories (OBQ11)
0.039 0.025
1.793 1.149
0.310 0.377
1.345 1.488
86.48 (39) 18.21 (22)
<0.001 0.693
0.92 0.92
0.480 (1.750) 0.300 (1.829)
observed for a majority of the remaining items. This
suggests that respondents had difficulties distinguish-
ing between response categories, threatens both the
user-friendliness of the scale and the interpretability
of responses, and was likely related to too many
response categories. Other reasons may also include
multidimensionality [19], which appeared to be the
case for three items, or local response dependence
[23,29], which was indicated for four items (Table 3).
Based on these observations, we explored the effects
of step-wise collapsing response categories. First, we
collapsed the first and second response categories and
after that also the third and fourth response catego-
ries. Following this, the rating scale worked as
intended (data not shown). Thus, the response cate-
gories were reduced from six to four (0 ¼ completely
disagree, 1 ¼ tend to disagree, 2 ¼ tend to agree, and
3 ¼ completely agree).
New data were then collected with this revised ver-
sion of the OBQ (Sample 2). Sample 2 consisted of
207 persons aged 20–89. The mean (SD) age was 50
(13) and 64 per cent were women. As suggested by
our observations with the experimentally collapsed
response categories in sample 1, there were no disor-
dered thresholds in sample 2 (Figure 1). The revised
OBQ with four response categories showed good reli-
ability and improved overall fit (Table 2). Table 3
shows individual item fit statistics for the OBQ with
13 items following reduction to four response catego-
ries. Three items showed signs of misfit. In two of
these (items 3 and 6) fit residuals outside the range
(4.034 and 2.902, respectively) suggest multidimen-
sionality. These items were, therefore, reviewed rela-
tive to the definition of occupational balance, i.e. ‘the
experience of having the right amount of occupations
and the right variation between occupations in the
 SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 5

occupational pattern’ [6, p. 326]. In view of this, item

Chi-sq (p-value ) Location order Item location (SE) Fit residuala Chi-sqb (p-valuec)

Summarize the deviation of observed from expected responses across sample class intervals. Bonferroni corrected statistically significant (at a level of <0.05) deviations across class intervals, indicating item misfit
1.546 (0.462)
0.724 (0.696)

2.498 (0.287)
2.761 (0.251)

0.483 (0.786)
0.930 (0.628)
4.352 (0.113)
0.817 (0.665)
2.209 (0.331)
0.912 (0.634)
0.980 (0.613)
3 (Perceiving one’s occupations as meaningful) and
OBQ11 with 11 items, 4 response categories (Sample 2)
item 6 (Balance between doing things alone and with


others) have nothing to do with the amount or vari-
ation of occupations but instead they have something
to do with personal or environmental aspects that of
1.080
0.673

1.905
1.678

0.432
0.020
1.783
0.904
0.641
0.642
0.362



course influence occupational balance, but the pur-
pose of the OBQ is not to measure these aspects but
rather the experience of the amount of and variation
0.304 (0.119)
0.097 (0.123)

1.022 (0.135)
0.378 (0.129)

0.111 (0.127)
0.199 (0.130)
0.300 (0.127)
0.651 (0.131)
0.109 (0.127)
0.324 (0.126)
0.267 (0.113)
between different occupations in the occupational pat-


tern. Therefore, first item 3 was removed but item 6

was still misfitting. When both items were removed
all residuals were nonsignificant and within the
acceptable range of 2.5 to 2.5 (Table 3). Relative
correlations between standardized item residuals did
9
4

1
11

3
6
8
2
5
10
7


not exceed 0.2, which supports the absence of mean-

ingful local dependence and further strengthens valid-
ity. We refer to this revised version, with 11 items
c

(<0.001)

(<0.001)

(0.003)
(0.276)
(0.646)

(0.178)
(0.159)

(0.781)
(0.331)

(0.717)
(0.176)
(0.067)
(0.921)

and four response categories, as the OBQ11.

OBQ with 13 items, 4 response categories (Sample 2)

However, item 4 (Time for doing things wanted)

5. 418
2.573
0.874
18.171
3.453
3.682
17.419
0.495
2.207
11.962
0.665
3.472

0.163
b

exhibited uniform DIF by gender, with women scor-

ing systematically higher than men. Item 7 (Have suf-
a
Chi-sq (p-value ) Location order Item location (SE) Fit residual

ficient time for doing obligatory occupations)

4.043

2.902
0.320
0.297

0.768
1.659

0.521
0.884
2.263
0.035
1.130
1.706
0.041

exhibited uniform DIF by age, with older people scor-

ing systematically higher than younger people. This
indicates that these items do not work the same way
(0,113)
(0.117)
(0.127)
(0.130)
(0.123)
(0.116)
(0.121)
(0.125)
(0.122)
(0.126)
(0.121)
(0.121)
(0.107)

in different groups. The observed DIF was adjusted

for by splitting item 4 into one female- and one
0.516
0.137
2.188
0.774
0.577
0.305
0.140
0.427
0.502
0.375
0.343
0.536
0.465

male-specific item, and item 7 into one for older and

one for younger people. The intraclass correlations
between person locations from the original and DIF-
adjusted person estimations were 0.99 (item 4) and
10
3
1
13
12
5
4
7
9
2
6
11
8

1.0 (item 7). Furthermore, when comparing the differ-

Should be non-significant, Bonferroni corrected (each item’s fit to the model).

ences between mean person locations based on the

(<0.001)

(<0.001)
c

(<0.001)

(<0.001)

original and the DIF-adjusted items, effect sizes of

(0.009)
(0.002)
(0.859)

(0.307)
(0.688)
(0.337)
(0.386)

(0.080)

(0.479)

0.03 (item 4) and 0.009 (item 7) suggest that the

OBQ with 13 items, 6 response categories (Sample 1)

observed DIF do not appear to cause any obvious

Should be between 2.5 and 2.5, item misfit is shown in bold.
0.761
19.358
3.074
1.477
3.375
3.036
17.711
6.767
18.159
2.479
18.705
11.532
14.728
b

bias to the OBQ as a measure of occupational bal-

ance. Therefore, both items were retained in their ori-
a
Item Location order Item location (SE) Fit residual

3.552

3.866
23.141
24.683

25.646
23.105
4.138
0.672

1.866
0.918
1.274
1.566

0.696

ginal format.
The OBQ11 did not exhibit any floor effects, and a
3% (n ¼ 6) ceiling effect. Figure 2 shows the distribu-
Table 3. Rasch item and fit statistics.

tion of persons and item response category thresholds

(0.052)
(0.055)
(0.056)
(0.054)
(0.052)
(0.053)
(0.051)
(0.055)
(0.054)
(0.049)
(0.053)
(0.053)
(0.051)

along the common logit metric of the new OBQ11.

0.178
0.234
0.690
0.425
0.224
0.098
0.074
0.157
0.017
0.243
0.200
0.439
0.063

Good distribution means that the scale represents the

levels of occupational balance reported by the sample.
and bolded in the table.

A mean person location of < ±0.5 logits has been

suggested to indicate good targeting [30]. In Figure 2
9
3
1
2
11
4
5
8
6
12
10
13
7

the mean (SD) person location is 0.3 (1.83) logits.

Furthermore, it is evident that the scale is able to sep-
arate persons (Figure 2, upper panel; PSI, 0.92) and
10
11
12
13

that it maps out a quantitative continuum from more

1
2
3
4
5
6
7
8
9

b
a

c
6 C. HÅKANSSON ET AL.

Figure 1. Response category thresholds for each item (in location order from easiest to hardest to achieve) on the Occupational
Balance Questionnaire with four response categories and 13 items.

Figure 2. Distribution of locations of persons (upper panel) and response category thresholds (lower panel) in sample 2 (OBQ11,
11 item and 4 response categories).

to less (Figure 2, lower panel). Item locations are cov-
ered by the persons, meaning that the basic premises
for evaluating the scale are good. However, the range
of person locations is not optimally represented by
item locations, as illustrated by a relatively large gap
between approximately 0.2 and 1.8 logits, a some-
what smaller gap between about 1 and 2 logits, and
non-coverage of persons at the extreme levels of occu-
pational balance (Figure 2, lower panel). This means
that the OBQ11 measures with less precision at
these intervals.
As illustrated in Table 3, there was support for the
logic of the hierarchical item ordering relative to pre-
vious research [31,32]. That is, being able to do what
one wants is relatively easy to achieve (i.e. does not
require very high levels of occupational balance),
while experiencing balance between different types of
occupations may be more difficult to achieve. For
example, item 4 (Time for doing things wanted) rep-
resents the lower end of the OBQ11 continuum
(1.022 logits) and item 5 (Balance between work,
home, family, leisure, rest, and sleep) represents the
highest level of occupational balance (0.378 logits).
When taking measurement uncertainties (±2 SEs)
into account, one item (number 11) exhibited differ-
ent locations in the new OBQ11 compared to the ori-
ginal OBQ.
Discussion
The present study investigated the validity of the
OBQ using RMT resulting in a new version of the

instrument, the OBQ11. As opposed to previous CTT
based analyses [7], several important features were
revealed. First, the original response scale did not
work as intended and reduction from six to four
response categories improved the questionnaire with-
out loss of reliability. Second, two items signaled mis-
fit due to multidimensionality, which could be
understood theoretically, thus resulting in a conceptu-
ally clearer and reliable 11-item questionnaire, with
four functioning response categories, acceptable
model fit, measurement invariance across age and
genders, and probably a logical hierarchical item
ordering. The evaluation of the logical hierarchical
item ordering is based on two previous studies
[31,32] but more research is needed to be sure.
In the analysis of the OBQ, data suggested that
item 3 (Perceiving one’s occupations as meaningful)
and item 6 (Balance between doing things alone and
with others) may represent a construct other than
occupational balance. As with all other items, these
items were derived from empirical studies. In a quali-
tative study [8], women with stress-related disorders
emphasized the importance of meaningful occupa-
tions to experience occupational balance.
Furthermore, in a previous literature review [33] one
of four identified perspectives of occupational balance
was congruence between values and occupations.
According to another definition [34, p. 231] occupa-
tional balance is ‘the extent to which a pattern of
occupation is perceived as harmonious, fulfilling, and
compatible with one’s values’. When developing item
3, we, therefore, considered occupations perceived as
meaningful to be an indicator of occupational bal-
ance. Very likely meaningfulness is affected by the
environment and meaning affects occupational bal-
ance but is not an indicator of occupational balance.
Regarding item 6, women with stress-related disorders
have emphasized the importance of balance between
doing occupations alone and together with others [8].
However, we have not found any other support for
this. Other people are part of the environment and
thus not an indicator of occupational balance. As the
OBQ11 is a short instrument, focusing on measuring
occupational balance from the perspective of people’s
experience of their amount and variation of occupa-
tions regardless of which these are, it is suitable to
combine OBQ11 with measurements of other aspects
of occupational balance such as the LBI [2]. Also,
combining the OBQ11 with measures of occupational
meaning or value, such as the Occupational Value
Assessment with predefined items (OVal-pd) [35],
and measures of the social environment [36] is likely
SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 7
a feasible approach to capture a wider array of
important aspects that affect occupational balance.
The results further show a slight but general ten-
dency for the items to represent less occupational bal-
ance than that experienced by the persons, and we
found gaps along the occupational balance continuum
that are not represented by the OBQ11. This may
have practical implications, such as the OBQ11 being
less suitable for detecting differences between people
with higher occupational balance or to follow changes
over time in such samples. However, this is not con-
sidered a major problem because precision is of less
concern at the highest levels of occupational balance,
as those with high occupational balance do not need
to improve their occupational balance. Of somewhat
more concern are the two gaps in the item coverage,
which comprise measurement precision at levels of
occupational balance represented by a majority of
people. One obvious way to improve precision and
targeting would be to increase the number of items
and/or response categories to enhance the representa-
tion of the latent occupational balance continuum.
Given the evidence that a four-category response scale
is preferable to six response categories, it seems rea-
sonable to suggest that future efforts should attempt
to identify additional items rather than expanding the
number of response categories.
A limitation of the present study was that mean
age was around 50 and that two thirds were women.
This may have affected the results as previous studies
have shown that occupational balance differs between
men and women [31] between people with and with-
out children [37] and probably between people with
disabilities and without them. Therefore, the OBQ11
needs to be tested in additional samples of other ages
and a more even gender distribution. Furthermore, it
also has to be tested in various patient groups as well
as across countries and cultures.
It may also be argued that the sizes of our samples
were somewhat limited, particularly regarding sample
1. However, the primary purpose of sample 1 was to
get an initial indicator of any major issues related to
the OBQ. As such, a sample size of about 150 can be
considered as acceptable [38]. As for sample 2, it has
been found that samples of about this size represent a
fair balance with regard to assessment of fit to the
Rasch model using the RUMM2030 software [28].
Practical implications
Since occupational balance is an essential aspect of
occupational therapy it is vital to be able to measure
8 C. HÅKANSSON ET AL.
it. This study suggests that the OBQ11 may serve to
fill this gap by providing a valid and reliable measure
of occupational balance. The OBQ11 may have prac-
tical relevance as a tool to identify occupational bal-
ance in general populations. The OBQ11 can be used
as a screening tool to prioritize clients for occupa-
tional therapists and for intervention planning in
health promoting occupational therapy. In the present
study a general population was selected, but the
OBQ11 needs to be tested in clinical samples too.
Conclusions
The new version of the Occupational Balance
Questionnaire with 11 item and four response catego-
ries, the OBQ11, satisfies the measurement criteria
defined by RMT and may provide a useful means to
assess experienced occupational balance both in
groups and individuals. However, further studies are
needed to validate the OBQ11 across a wider range of
applications.
Acknowledgements
The authors want to thank all participating respondents,
and the occupational therapy students for their valuable
help with data gathering.
Disclosure statement
The authors report no conflict of interest.
ORCID
Carita Håkansson http://orcid.org/0000-0002-3660-3079
Peter Hagell http://orcid.org/0000-0003-2174-372X
References
[1] Meyer A. The philosophy of occupation therapy.
Am J Occup Ther. 1977;31(10):639–642. (Reprinted
from Arch Occup Ther 1922;1:1-10).
[2] Matuska K. Description and development of the life
balance inventory. Occup Ther J Res. 2012;32:
220–228.
[3] Matuska KM, Christiansen CH. A proposed model
of lifestyle balance. J Occup Sci. 2008;15(1):9–19.
[4] Eakman A. The meaningful activity wants and needs
assessment: a perspective on life balance. J Occup
Sci. 2015;22(2):210–227.
[5] D€ur M, Steiner G, Fialka-Moser V, et al.
Development of a new occupational balance-ques-
tionnaire: incorporating the perspectives of patients
and healthy people in the design of a self-reported
occupational balance instrument. Health Qual Life
Outcomes. 2014;12(1):45.
[6] Wagman P, Håkansson C, Bj€ orklund A.
Occupational balance as used in occupational ther-
apy. A concept analysis. Scand J Occup Ther. 2012;
19(4):322–327.
[7] Wagman P, Håkansson C. Introducing the
Occupational Balance Questionnaire (OBQ). Scand J
Occup Ther. 2014;21(3):227–231.
[8] Håkansson C, Dahlin-Ivanoff S, Sonn U. Achieving
balance in everyday life. J Occup Sci. 2006;13(1):
74–82.
[9] Wagman P, Bj€orklund A, Håkansson C, et al.
Perceptions of life balance among a working popula-
tion in Sweden. Qual Health Res. 2011;21(3):
410–418.
[10] Wagman P, Håkansson C, Jacobsson C, et al. What
is considered important for life balance? Similarities
and differences among some working adults. Scand J
Occup Ther. 2012;19(4):377–384.
[11] Hobart JC, Cano SJ, Zajicek JP, et al. Rating scales
as outcome measures for clinical trials in neurology:
problems, solutions, and recommendations. Lancet
Neurol. 2007;6(12):1094–1105.
[12] Hobart J, Cano S. Improving the evaluation of thera-
peutic interventions in multiple sclerosis: the role of
new psychometric methods. Health Technol Assess.
2009;13(12):1–200.
[13] Hagell P. Measuring activities of daily living in
Parkinson’s disease: on a road to nowhere and back
again? Measurement. 2019;132:109–124.
[14] Rasch G. Probabilistic models for some intelligence
and attainment tests. Copenhagen: Danish Institute
for Educational Research; 1960.
[15] Andrich D. Rasch models for measurement.
Newbury Park, [Calif.]; London: SAGE, Cop. 1988.
[16] Mari L, Wilson M. An introduction to the Rasch
measurement approach for metrologists.
Measurement. 2014;51:315–327.
[17] Pendrill L. Man as a measurement instrument.
NCSLI Meas. 2014;9(4):24–35.
[18] Wilson M. Constructing measures: An item response
modelling approach. Mahwah, NJ: Lawrence
Erlbaum Associates Inc; 2005.
[19] Wolfe EW, Smith EV. Instrument development tools
and activities for measure validation using Rasch
models: part II – validation activities. J Appl Meas.
2007;8(2):204–234.
[20] Andrich D. An index of person separation in latent
trait theory, the traditional KR-20 index, and the
Guttman scale response pattern. Educ Psychol Res.
1982;9:95–104.
[21] Andrich D, Luo G, Sheridan B. Interpreting RUMM
2030. Perth: WA: RUMM Laboratory, 2013.
[22] Andrich D. Rating scales and Rasch measurement.
Expert Rev Pharmacoecon Outcomes Res. 2011;
11(5):571–585.
[23] Marais I. Local dependence. In KB Christensen,
S Kreiner, M Mesbah (Eds.). Rasch models in health.
Croydon, Surrey, UK: John Wiley & Sons, 2013. pp.
111–130.
[24] Christensen KB, Makransky G, Horton M. Critical
values for Yen’s Q 3: identification of local

dependence in the Rasch Model using residual cor-
relations. Appl Psychol Meas. 2017;41(3):178–194.
[25] Hagquist C, Andrich D. Recent advances in analysis
of differential item functioning in health research
using the Rasch model. Health Qual Life Outcomes.
2017;15(1):181.
[26] Andrich D, Sheridan B, Luo G. RUMM2030: Rasch
unidimensional models for measurement. Perth,
Australia: RUMM Laboratory; 1997.
[27] Bland JM, Altman DG. Multiple significance tests:
the Bonferroni method. BMJ. . 1995;310(6973):170.
[28] Hagell P, Westergren A. Sample size and statistical
conclusions from tests of fit to the Rasch Model
according to the Rasch unidimensional measurement
model (RUMM) program in health outcome meas-
urement. J Appl Meas. 2016;17(4):416–431.
[29] Hagqvist C. Evaluating composite health measures
using Rasch modelling: an illustrative example. Soz
Praventivmed. 2001;46:369–378.
[30] Hudgens S, Dieneen K, Webster K, et al. Assessing
statistically and clinically meaningful construct defi-
ciency/saturation: recommended criteria for content
coverage and item writing. Rasch Meas Trans. 2004;
17:954–955.
[31] Håkansson C, Ahlborg G. Perceptions of employ-
ment, domestic work, and leisure as predictors of
health among women and men. J Occup Sci. 2010;
17(3):150–157.
SCANDINAVIAN JOURNAL OF OCCUPATIONAL THERAPY 9
[32] Håkansson C, Bj€ orkelund C, Eklund M. Associations
between women’s subjective perceptions of daily
occupations and life satisfaction, and the role of
control. Aust Occup Ther J. 2011;58(6):397–404.
[33] Wada M, Backman CL, Forwell SJ. Theoretical per-
spectives of balance and the influence of gender
ideologies. J Occup Sci. 2010;17(2):92–103.
[34] Backman C. Occupational balance and well-being.
In CH Christiansen, EA Townsend. Introduction to
occupation. The arts and science of living. Upper
Saddle River, NJ; Pearson Education Inc. 2010.
[35] Eklund M, Erlandsson L-K, Persson D, et al. Rasch
analysis of an instrument for measuring occupa-
tional value: Implications for theory and practice.
Scand J Occup Ther. 2009;16(2):118–128.
[36] Kjellberg A, Haglund L. Utilization of the Swedish
version of the assessment of communication and
interaction skills. Br J Occup Ther. 2016;79(4):
228–234.
[37] Wagman P, Håkansson C. Exploring occupational
balance in adults in Sweden. Scand J Occup Ther.
2014;21(6):415–420.
[38] Regnault A. A mixed methods framework for the
development of patient-centered outcome measures.
Paper presented at the 7th International Conference
on Probabilistic Models for Measurements. Perth,
Australia 17-19 January, 2017.