Critical Review

Definitions of occupational balance and theircoverage by instruments

Mona Dur1, Julia Unger2, Michaela Stoffer3, Razvan Dragoi4,Alexandra Kautzky-Willer5, Veronika Fialka-Moser6, Josef Smolen7 andTanja Stamm8

AbstractIntroduction: 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 inresearch studies are diverse as well. Consequently, it is unclear how instruments and definitions correspond. The purpose of thisstudy 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 ofexisting instruments. Definitions and items were extracted from articles identified in a systematic literature search. The extent ofcongruence 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 definitionswere a balance of ‘various occupational patterns and areas’ (42; 89%) and ‘occupational accomplishment, performance, roles andresponsibilities’ (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.

KeywordsOccupational science, assessments, content analysis, outcome research, conceptualisation

Received: 4 February 2014; accepted: 7 July 2014

Introduction

Occupational balance is an important concept in occupa-tional therapy and occupational science. Occupationalbalance has been considered as crucial for health and well-being since the very beginning of occupational therapy(Meyer, 1977; Rogers, 1984). Occupational therapists cur-rently explore various concepts to get a comprehensivepicture of occupation, such as occupational balance(Creek, 2010; Gutman and Schindler, 2007). In order toidentify patients’ needs for interventions that target occu-pational balance (AOTA, 2011), and to evaluate theire!ects, occupational therapists need to know underlyingdimensions and how to measure them.

There is no single definition of occupational balance(Anaby et al., 2010b). Most recently, occupational balancewas defined as subjective ‘perception of having the rightamount and variation of occupations’ (Wagman et al.,2012a). Furthermore, occupational balance is occasionallyused in relation to or synonymously with life balance, life-style balance or work–life balance (Matuska, 2012b;Wagman et al., 2012b). Occupational therapists need atangible definition of occupational balance, which shouldreflect the concept as accurately as possible to contributeto the comparability of studies on occupational balance.

Definitions of occupational balance have been explored inexisting literature. Two of these articles address the urgenttask not only to provide a concise definition of occupational

1Lecturer and Researcher, Department of Health Sciences, IMC University ofApplied Sciences Krems, Austria; Lecturer, Researcher and PhD Candidate,Medical University of Vienna, Vienna, Austria2Lecturer and Researcher, FH Joanneum, Bad Gleichenberg, Austria3Research Fellow and PhD Candidate, Department of Internal Medicine,Medical University of Vienna, Vienna, Austria4Assistant Professor, Department of Rehabilitation, Physical Medicine andRheumatology, Victor Babes University of Medicine and Pharmacy,Romania5Head of Gender Medicine Unit, Deputy Head of Internal Medicine III,Medical University of Vienna, Vienna, Austria6Head of Department of Physical Medicine and Rehabilitation, MedicalUniversity of Vienna, Vienna, Austria7Head of Department of Internal Medicine III, Medical University of Vienna,Vienna, Austria8University of Applied Health Sciences, Austria

Corresponding author:Tanja Stamm, Head of Research Group for Clinimetrics, Department ofInternal Medicine III, Division of Rheumatology, Medical University ofVienna, Spitalgasse 23, A-1090 Vienna, Austria, and Head of MasterDegree Program ‘‘Health Assisting Engineering’’, FH Campus Vienna,Favoritenstraße 226, 1100 Vienna, Austria.Email: tanja.stamm@meduniwien.ac.at

The British Journal of Occupational

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balance, based on current literature, but also to explore thehistory and variety of definitions for occupational balance(Backman, 2004; Wagman et al., 2012a). For example,Wagman et al. (2012a) used a concept analysis to clarify thecontent of occupational balance definitions and finally gave aconcise definition. Furthermore, three perspectives werefound to be used in relation to occupational balance(Wagman et al., 2012a). The results did not assign certainarticles to the identified concepts referring to occupationalbalance. Furthermore, the frequency of their occurrence wasnot reported. Additionally, the conceptualisation of balancewas explored previously (Reece et al., 2009;Wada et al., 2010;Westhorp, 2003). Wada et al. (2010) examined di!erent con-cepts and perspectives of balance, including occupational andlife balance (Wada et al., 2010). However, the conceptualisa-tion of occupational and life balance was not described anddiscussed extensively. Thus, these articles did not report datathat could be further used to explore the coverage of the def-initions of occupational and/or life balance by existing instru-ments. Moreover, both articles did not provide a detailedpresentation of the di!erent contents of the definitions witha systematic illustration of the methods used and the resultsextracted. From this point on the term ‘instruments’ encom-passes measurements, questionnaires and single items.

Numerous instruments are currently available that can beused to assess occupational balance. Based on the di!erentexisting definitions, instruments that measure the concept inresearch studies are diverse as well. Consequently, it isunclear how instruments and definitions correspond. If occu-pational therapists want to select an instrument to evaluatetheir interventions, they need to know which dimensions areor are not covered by an instrument and about their psy-chometric properties (Mokkink et al., 2010a, 2010b). Thepsychometric properties of several instruments to measureoccupational balance have been discussed and criticallyappraised elsewhere (Anaby et al., 2010b; Backman, 2001;Bejerholm and Eklund, 2006a; Christiansen, 1996;Hakansson et al., 2009). However, there is no content com-parison of the existing instruments and the dimensions ofoccupational balance covered by these instruments. Such anoverview would help clinicians and researchers to easilyselect the appropriate instrument. Thus, we find it is impera-tive to first compare definitions currently used. In order toadd value to the currently existing gap of information aboutoccupational balance definitions and instruments, a system-atic literature search and content analysis is needed.

The purpose of this study was to examine the coverageof occupational balance definitions by occupational bal-ance instruments. Therefore, we aimed to (a) identify exist-ing occupational balance definitions and instruments thatwere developed and/or used to measure occupational bal-ance, (b) examine their contents and (c) explore whichinstruments cover those definitions.

Methods

Within a mixed-methods design we conducted a qualita-tive and quantitative content analysis (Creswell, 2003) sep-arately, of definitions and items of existing instruments.

Definitions and items were extracted from articles identi-fied in a systematic literature search. The extent of con-gruence and coverage between definitions and instrumentswas examined.

Systematic literature search

In the first step, a systematic literature search was con-ducted to identify articles on and definitions of ‘occupa-tional balance’ and ‘life balance’, as well as instrumentsthat were developed or used to measure these concepts.The search was done in 2013 using PubMed, CINAHLand Web of Science.

To be eligible for review, an article needed to meet thefollowing inclusion criteria: titles and abstracts containingthe keywords ‘occupational balance’ or ‘life balance’; anexplicit definition of occupational and/or life balance ordescription of an instrument used to measure occupationaland/or life balance; published in English in a peer-reviewedscientific journal; and had at least one author who was anoccupational therapist. The latter criterion was establishedto find articles relevant to occupational therapy, and toavoid the identification of articles that refer to occupationas paid work exclusively. Additionally, articles referring to‘postural’ or ‘physical’ balance, or related ‘balance dis-orders’ were excluded due to irrelevance. Life balance wasused as a keyword because some authors refer to this termas occupational balance synonymously (Matuska, 2012b;Wagman et al., 2012b). However, in order to provide infor-mation about which articles were identified by the search onwhich term (occupational or life balance) and which cate-gories have been used in relation to which concept, theresults were presented separately. Articles referring to ‘bal-ance of occupations’, ‘work–life balance’, ‘lifestyle balance’and a ‘balanced life’ were included. Year of publication wasnot a criterion for inclusion of an article.

Once candidate articles were identified, they were inde-pendently reviewed by three researchers (MD, JU andAlexa Binder [AB]) through the use of a data extractionform to extract occupational and/or life balance definitionsand occupational or life balance instruments. The teammembers verified the accuracy of data extraction by con-currence. The selected articles were read mindfully by thethree researchers. All sections (abstract, introduction, meth-ods, results, discussion and conclusions) were screened fortext sequences referring to ‘occupational’ and/or ‘life bal-ance’. Those definitions that were identified by the threeresearchers were selected. In case of disagreement, discussionled to a shared decision and the selection or exclusion of atext sequence. Subsequently, the content of these textsequences on occupational and/or life balance was listedand used for further analysis. Similarly, a data extractionform was used to identify instruments measuring one ormore aspects of occupational and/or life balance. To be eli-gible, an instrument needed to have a stated purpose to bedeveloped or used as measurement of occupational and/orlife balance, identified by two researchers (MD and JU). Incase of disagreement, a third researcher (AB) made a deci-sion regarding the selection or exclusion of an instrument.

Dur et al. 5

Since it was not the aim of this project, we did not considerother psychometric properties of the instruments. If theitems of an instrument were not specified in the article theywere extracted from the original source.

Qualitative content analysis

Both occupational and life balance definitions, as well asinstruments’ items, were then listed and thematically clus-tered by the use of meaning categorisation, a qualitativecontent analysis, as described by Kvale (1996). First, theselists were reduced by the creation of sub-categories, thuscondensing the meaning of the original definitions or instru-ment items. Second, overlapping categories were combined(details are explained in the example at the results section).The meaning of the selected definitions and items wasexplored and categorised by two authors independently (def-initions: AB and MD; instruments: MD and JU). The iden-tified categories did not have to be mutually exclusive, basedon their occurrence in the text sequences referring to occu-pational and/or life balance. Items that did not result in thesame interpretation by both analysts were discussed. In add-ition to this exchange, a third occupational therapist, notinvolved in the previous analysis (Stefanie Haider), wasasked to mediate this process and come to a decision. Thisprocess was completed and documented in Excel files. Theidentified categories within the selected articles, as well as thecategories identified in the instruments, were summarised.One item could encompass more than one category. Belowwe provide an example of the analysis in which sub-cate-gories and categories were created based on a specificquote. In Eklund et al. (2009b), occupational balance isdefined as ‘a balance between work, rest and play measuredin time’. Based on this quote, the following two sub-cate-gories were created: a ‘balance of work, rest and play’ and a‘balance of time used for work, rest and play’. Out of thefinal 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 analysisand used descriptive statistics to explore the frequency ofthe identified categories and the extent of their coverage bythe instruments. The number of articles per identified cat-egory was calculated. Categories mentioned only in a max-imum of three articles (1.3%) were not considered forfurther investigation. Additionally, categories identified inmore than two-thirds (>66%) of the articles were defined asthe ‘core’ dimensions of occupational and life balance.

In the final step, the researchers matched instruments todefinitions in order to report how many instruments wereavailable to assess each category of occupational and lifebalance definitions and to note definitions for which noinstrument 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, 16on occupational balance in PubMed, 43 in CINAHL and18 in Web of Science. The literature search on life balancebrought 263 results in PubMed, 43 in CINAHL and 134 inWeb of Science. Of these, 26 articles were duplicates andwere therefore removed; another 444 articles wereexcluded due to their irrelevant contents. Finally, 47 art-icles were used for further analysis: 26 articles on occupa-tional balance, 15 articles on life balance and six whichcontained both occupational and life balance in the titlesand/or abstracts. Consequently, a total of 32 articles on OBand a total of 21 articles on LB, of which six were the same,were used for further analyses. Of the 47 articles, 13 pro-vided information on the instrument items, while six add-itional articles were used to obtain instrument items. Thus,a total of 19 articles were used for the extraction of instru-ment items. The articles’ selection process by the literaturesearch is shown in Appendix 1 (Moher et al., 2009).

In the tables, we referred to the specific articles and instru-ments thematically in an alphabetical order of the firstauthors’ names using the reference number of the articles,as listed in Appendix 2.

We found 21 articles that described the use or develop-ment of 17 di!erent occupational balance and two lifebalance instruments, and one instrument (Q sort pack)(Wagman et al., 2012b) that measured both occupationaland life balance. Half of the articles reported the use ofone instrument, eight articles described the use of two tothree instruments and one article referred to the use offour di!erent occupational balance instruments. The lastrow of Table 1 represents the number of identified occu-pational and life balance instruments per article. In total,20 instruments were described.

Identified categories

Definitions. We identified 96 sub-categories in the extractedoccupational and life balance definitions, which were finallycombined into a total of 19 categories (see Table 1, firstcolumn (columns ! articles; rows ! categories)). An exam-ple is the category ‘equilibrium and congruence amongoccupations’. It contained the following sub-categories: sat-isfaction and dissatisfaction of occupations; congruencebetween desired, ideal and actual occupational patterns; con-gruence and equivalence in activity configuration; equiva-lence in the degree of discrepancy between desired andactual time spent across activities that meet di!erent needs.

The following categories were identified as ‘core’dimensions: a balance of ‘various occupational patternsand areas’ (42; 89%); ‘occupational accomplishment, per-formance, roles and responsibilities’ (35; 75%); ‘determin-ant of health’ (34; 72%); a balance of ‘time spent, time use,time pressure, pace and/or rhythm’ and ‘capabilities andchallenges’ (both 33; 70%). The percentage of the numbersof articles per category is presented in Appendix 3.

6 The British Journal of Occupational Therapy 78(1)

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8 The British Journal of Occupational Therapy 78(1)

Within the definitions of occupational and life balance,the following categories were identified at an almost equalfrequency: ‘determinant of health (occupational balance !24; 75% vs. life balance ! 16; 76%), ‘occupational accom-plishment, performance, roles and responsibilities’ (24; 75%vs. 15; 71%), ‘time spent, time use, time pressure, pace and/orrhythm’ (20; 63% vs. 15; 71%), ‘chosen and obligatory occu-pations’ (10; 31% vs. 5; 24%), ‘capabilities and challenges’(22; 69% vs. 13; 62%) and ‘subjective and individual’ (12;38% vs. 7; 33%). ‘Biological need’ wasmentioned in relationto occupational balance only. While life satisfaction was fre-quently quoted as being essential for life balance (6; 29%),‘engagement in meaningful occupations’ was mainly relatedto occupational balance (11; 34%). The categories ‘a!ectiveexperience’, 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 occu-pational balance articles used occupational balance syn-onymously with life balance (16%) and 12 did so withlifestyle balance (38%). More articles reported the develop-ment 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 instru-ments, we were able to identify a total of 65 categories.The instruments consisted of 251 items which were usedfor further investigation. The instruments’ characteristicsare briefly described in Table 2.

Instruments’ coverage of the definitions

The instruments’ coverage of the definitions is depicted inTable 3. Most often the instruments covered a balance in‘various occupational patterns and areas’ (14; 70%), a bal-ance of ‘time spent, time use, time pressure, pace and/orrhythm’ and ‘equilibrium and congruence among occupa-tions’ (both 12; 60%). Another frequently measured cat-egory was a balance of ‘occupations (more and less)meaningful for the individual and the socio-cultural con-text’ (11; 55%). Sixteen (84%) of the 19 categories thatwere identified in the definitions were also covered by theinstruments. The ‘Q sort pack’ (I-18) covered 13 categories(68%). The ‘time structure questionnaire’ (I-6, TSQ)(Bond and Feather, 1988), the ‘experiences of engagementin patterns of daily occupations’ questionnaire (I-10)(Hakansson et al., 2009), and the ‘occupational valueinstrument with predefined items’ (I-17, OVal-pd)(Eklund et al., 2003) covered eight categories each(42%), which were also identified in the definitions.Compared with their frequent use in articles, a balanceof ‘occupational accomplishment, performance, roles andresponsibilities’ and ‘capabilities and challenges’ were cov-ered by few instruments (7; 35%, and 6; 30%, respect-ively). A balance of ‘abilities and restrictions to adaptoccupations’ – for example to changed life circumstances– was covered only once, by the ‘Q sort pack’ (I-18). Thecategories ‘individuality and subjectivity’ and the ‘dynamicstate of occupational or life balance’ were not covered bythe instruments (items). Nevertheless, the category

‘individuality and subjectivity’ is covered by some of theinstruments due to the fact that they assess patients’ per-spectives. The health determining e!ect of occupationaland life balance was covered by two instruments:Wilcock’s ‘Questionnaire on involvement in occupations’(I-14) (Wilcock, 1997) and the ‘Q sort pack’ (I-18).

Discussion

To our knowledge, this is the first study searching system-atically for occupational and life balance instruments, andexploring their coverage of existing definitions of occupa-tional and life balance.

The results show that a balance of ‘various occupa-tional patterns and areas’, as well as of ‘occupationalaccomplishment, performance, roles and responsibilities’,(89% and 75%, respectively) were the most frequent cate-gories in the articles. The categories that were a balance of‘various occupational patterns and areas’ and of ‘timespent, time use, time pressure, pace and/or rhythm’ werethe most frequent dimensions covered by the instruments(70% and 60%, respectively). This may relate to the factthat these two categories are easier to measure than othercomplex dimensions of occupational balance (Eklundet al., 2010). Time is fundamental to how people organiseand structure their daily lives, and can therefore be linkedclosely to occupation (Edgelow and Krupa, 2011).However, in two previous qualitative studies, a balanceduse of time was not found to be meaningful concerningoccupational balance for people with a chronic disease,such as rheumatoid arthritis or Crohn’s disease (Duret al., 2014b; Stamm et al., 2009). Interestingly, the cat-egory balanced ‘occupational accomplishment, perform-ance, roles and responsibilities’ was found to be coveredby 35% of the instruments.

The category of ‘biological need’ was only identified inoccupational balance articles. Moreover, in a recent quali-tative study (Wagman et al., 2012b) occupational balancehas been found to be a part of life balance. In order toguide occupational therapists in their understanding of thetwo constructs, further studies on potential di!erences orsimilarities are suggested.

The health determining e!ect of occupational balancehas been reported frequently (Anaby et al., 2010a;Backman, 2004; Sandqvist et al., 2005; Wilcock, 1997).Surprisingly, even though occupational therapists are con-vinced that occupational balance has a positive e!ect onhealth (identified in 23 occupational balance articles,72%), it was found to be only measured by two instru-ments (Wilcock’s ‘Questionnaire on involvement in occu-pations’ [I-14] and the ‘Q sort pack’ [I-18]). Nevertheless,some of the studies included instruments that assess gen-eral health. In order to investigate this e!ect and a poten-tial link between occupation and health, instruments thatassess general health should be used in addition to occu-pational balance instruments.

Another fundamental belief of occupational therapistsis that engagement in meaningful occupations is an essen-tial part of occupational balance, as quoted frequently

Dur et al. 9

Table 3. Categories identified in the definitions of occupational and/or life balance covered by instruments to measure occupational and/or life balance.

Categories of OB and LB definitions

Instrument number (see Table 2)

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 # #Determinant of, or essential for, life satisfaction #Dynamic state and on-going process

Engagement in meaningful occupations # # #Equilibrium and congruence among occupationsy # # # # # # # # # # # #Subjective and individual

*abilities and restrictions to adapt occupations #*social, physical and mental wellbeing # # # # # # #*capabilities and challengesy # # # # # #*caring for oneself and others # # # #*chosen and obligatory occupations # # # #*harmony and conflict among occupations # # # #*occupations (more/less) meaningful for the individual and the

socio-cultural contexty# # # # # # # # # # #

*occupational accomplishment, performance, roles and responsibilitiesy # # # # # # #*various occupational patterns and areasy # # # # # # # # # # # # # #*occupational identity, controllability and manageability # # # # # # #*strenuous and restful occupations # # # # # #*time spent, time use, time pressure, pace and/or rhythmy # # # # # # # # # # # #

*: A balance of . . .; OB: occupational balance; LB: life balance; y: core dimensions, indicating that these categories were identified in more thantwo thirds of the articles; #: category is covered by the specific instrument.

Table 2. Characteristics of the identified instruments which were used, developed or suggested to measure occupational or life balance.

I-No. Name and content No. Items

I-1 Personal project analysis: project elicitation list and cross impact matrix (CIM) (Anaby et al., 2010b) [OB] 13

I-2 Inter-goal relations questionnaire (IRQ) (Anaby et al., 2010b), [OB] 5

I-3 Satisfaction with balance of time spent on occupational areas and patterns (Backman et al., 2004) [OB] 1

I-4 Instrument of occupational balance (Bejerholm, 2010) [OB] 3

I-5 Profiles of occupational engagement for people with schizophrenia (POES) (Bejerholm and Eklund, 2006b) [OB] 9

I-6 Time structure questionnaire (TSQ) (Bond and Feather, 1988) [OB] 26

I-7 Satisfaction with daily occupations (SDO) instrument (Eklund, 2004) [OB] 9

I-8 Yesterday diaries on temporal occupational patterns of the last 24 hours (Eklund et al., 2010) [OB] 4

I-9 Three dimensions of occupational balance (Forhan and Backman, 2010) [OB] 3

I-10 Experiences of engagement in patterns of daily occupations questionnaire (Hakansson et al., 2009) [OB] 8

I-11 Occupational balance item (also contained in the ‘experiences of engagement in patterns of daily occupations’ questionnaire)(Hakansson et al., 2011) [OB]

1

I-12 Occupational questionnaire (Smith et al., 1986) [OB] 4

I-13 Possible measures of occupational balance (Wagman et al., 2012a) [OB] 15

I-14 Two-pages questionnaire on involvement in physical, mental, social and rest occupations (Wilcock, 1997) [OB] 6

I-15 Occupation, what’s in it for me? (Wilson and Wilcock, 2005) [OB] 1/n.d.

I-16 Experience sampling methodology (ESM) (Csikszentmihalyi and Larson, 1987) [OB] 1/8

I-17 Occupational value instrument with predefined items (OVal-pd) (Eklund et al., 2003, 2009a) [OB] 26

I-18 Q sort pack (Wagman et al., 2012b) [OB, LB] 42

I-19 Meaningful activities and needs instrument (MAWNA) (Eakman, 2013) [LB] 21

I-20 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.

10 The British Journal of Occupational Therapy 78(1)

(34% of the articles) (Backman, 2004; Bejerholm andEklund, 2007). This belief is reflected by three instrumentswhich were found to assess ‘engagement in meaningfuloccupations’ (‘Profiles of occupational engagement forpeople with schizophrenia’ [POES, I-5, Bejerholm andEklund, 2006b], ‘Experiences of engagement in patternsof daily occupations’ questionnaire [I-10] and Wilcock’s‘Questionnaire on involvement in occupations’ [I-14]).Additionally, another related category, a balance of ‘occu-pations (more and less) meaningful for the individual andfor the socio-cultural context’, was found to be covered by11 instruments (55%). This category could be a comple-mentary issue to the measurement of engagement in mean-ingful occupations.

In our study, we identified a gap between the definitionsand instruments of occupational and life balance. Forexample, the dynamic state of occupational balance is notcovered by any instrument. Furthermore, there are severalcategories 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 thearticles, measured by 30% of the instruments).

Wada et al. (2010) characterised balance with quantity,congruence, fulfilment and compatibility. Wagman et al.(2012a) found that occupational balance was related tooccupational areas, occupational characteristics and timeuse. However, in the current study, the content of the def-initions of occupational and life balance were categorisedin smaller units. This enabled the assignment of certainarticles to certain categories used in relation to occupa-tional balance. Furthermore, the numerous categoriesidentified in the current project allowed a precise examin-ation and statement on their coverage by existing occupa-tional and/or life balance instruments. The numerouscategories identified in the current project allowed a pre-cise examination and statement on their coverage by exist-ing occupational and/or life balance instruments. Based onthe results of a systematic literature search, we were able togive an overview about existing occupational and life bal-ance instruments. Moreover, the findings of this study cansupport occupational therapists and other health profes-sionals in their selection of instruments to assess occupa-tional or life balance in practice and in research. Anexample are patients with rheumatoid arthritis: activitylimitations and participation restrictions can result in aloss of meaningful activities, such as engaging in sportsor attending social activities (Forhan and Backman,2010). Thus, occupational therapy interventions thatimprove functioning support the (re-) establishment of abalance between di!erent occupations, such as self-care,productivity, leisure and rest. This could be assessed withone of the occupational balance instruments that cover thecategory that is a balance of ‘various occupational pat-terns and areas’. In addition, we suggest further researchto appraise other psychometric properties and thus com-plement the information that is important in assisting thechoice of an appropriate instrument. The ‘TSQ’ (I-6), the‘experiences of engagement in patterns of daily

occupations’ questionnaire (I-10) and the ‘OVal-pd’ (I-17) covered eight categories each. The ‘Q sort pack’ (I-18) covered 13 categories of the occupational and life bal-ance definitions. Since instruments with few items aremore applicable for clinical use, we suggest the develop-ment of a brief occupational balance instrument based onessential aspects important to patients.

Strengths and limitations

We included only articles published in peer-reviewed sci-entific journals. This could have limited the variety of thedi!erent contents of the occupational and life balance def-initions. Additionally, a search in di!erent databasescould have led to other findings and the identification ofmore occupational and life balance instruments. However,PubMed, CINAHL and Web of Science appeared to covermost peer-reviewed scientific journals relevant to occupa-tional therapists or occupational scientists. Additionally,original sources upon which the used occupational and/orlife balance definitions were based were not obtained.However, they were included for further analysis withinthe selected articles. Another limitation was that we didnot search explicitly for ‘occupational imbalance’ as arelated term. As it is unclear whether this is anotherstand-alone concept or an aberration of occupational bal-ance (Anaby et al., 2010a, 2010b), we decided not to lookspecifically for this keyword. The inclusion of the term ‘lifebalance’ seemed to be justified, since it is occasionally usedwith regards to occupational balance in occupational ther-apy literature (Backman, 2004). The fact that the meaningcategorisation was conducted by researchers who are alsooccupational therapists could have had an impact. Theinclusion of researchers with other professional back-grounds into this process may have led to di!erent find-ings. Moreover, the critical appraisal of current evidenceof instruments’ validities could have provided additionalimportant information. The detailed presentation of theresults increased the comprehensibility of the findings.Based on these findings, the need for further research,such as an analysis of the psychometric properties of theidentified occupational and life balance instruments,becomes clear. Additionally, empirical data as well asDelphi exercises could be used to find consensus on thedefinition of occupational balance.

Conclusion

The current definitions of occupational and life balanceused in scientific literature could be condensed to 19 cate-gories, of which 16 are covered by 20 identified occupa-tional and life balance instruments. Their examination cansupport occupational therapists, other health profes-sionals and health researchers to know which instrumentsare already used or developed to measure occupationalbalance. In addition, the findings of this study can assistthese people in their selection of instruments when assess-ing the need for, or evaluating the e!ect of interventionsaddressing, occupational balance.

Dur et al. 11

Key findings

Definitions of occupational balance contained 19 cate-gories. A total of 20 instruments were explored.Together they covered 16 (84%) categories. The categoryof 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 thatmeasure occupational balance. Knowing which instru-ments cover which dimensions can support occupationaltherapists to choose between occupational balanceinstruments.

AcknowledgementsWe would like to thank Alexa Binder for conducting the content ana-lysis of the articles. Furthermore, we want to thank the native speakersAndrea Jordan and Yvonne Schroder for proofreading, and StefanieHaider for the discussions on the meaning categorisation analysis.

Research ethicsEthics approval was not required for this study.

Declaration of conflicting interestNone declared.

FundingThis research was partly funded by a restricted grant from theAustrian Science Fund (FWF): [P21912-B09]. The FWF had no influ-ence on the content of the manuscript.

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Appendix 1. Flow diagram: article selection process based on a systematic literature search

14 The British Journal of Occupational Therapy 78(1)

Appendix 2. Article numbers

Appendix 3. Percentage of the numbers of articles describing a certain category

Categories of OB and LB definitions

Percentage of articles

All OB LB

Biological need 16 22 0

Determinant of healthy 74 71 67

Determinant of, or essential for, life satisfaction 16 3 33

Dynamic state and on-going process 58 61 44

Engagement in meaningful occupations 23 32 0

Equilibrium and congruence among occupationsy 67 54 83

Subjective and individual 35 39 33

*abilities and restrictions to adapt occupations 33 45 0

*social, physical and mental wellbeing 14 6 33

*capabilities and challengesy 70 68 61

*caring for oneself and others 26 8 4

*chosen and obligatory occupations 35 32 33

*harmony and conflict among occupations 26 29 11

*occupations (more/less) meaningful for the individual and the socio-cultural contexty 67 54 72

*occupational accomplishment, performance, roles and responsibilitiesy 79 74 89

*various occupational patterns and areasy 91 94 72

*occupational identity, controllability and manageability 40 23 67

*strenuous and restful occupations 51 54 33

*time spent, time use, time pressure, pace and/or rhythmy 74 64 72

*: A balance of . . .; OB: occupational balance; LB: life balance; All: percentage of all articles; y: core dimensions, indicating that these categorieswere identified in more than two-thirds of the articles.

No. References of OB articles No. References of OB articles No. References of LB articles

1 (Anaby et al., 2010b) 17 (Koome et al., 2012) 33 (Eakman, 2013)

2 (Backman, 2004) 18 (Ludwig et al., 2007) 34 (Hakansson et al., 2006)

3 (Backman et al., 2004) 19 (McGuire et al., 2004) 35 (Hakansson and Matuska, 2010)

4 (Bejerholm, 2010) 20 (Morgan 2010) 36 (Johansson et al., 2012)

5 (Dubouloz et al., 2004) 21 (Ottenvall Hammar and Hakansson, 2013) 37 (Lisson et al., 2013)

6 (Dur et al., 2014a) 22 (Pettican and Prior, 2011) 38 (Majnemer, 2010)

7 (Edgelow and Krupa, 2011) 23 (Sandqvist and Eklund, 2008) 39 (Matuska, 2012a)

8 (Eklund et al., 2009b) 24 (Stamm et al., 2004) 40 (Matuska, 2012b)

9 (Eklund et al., 2010) 25 (Stamm et al., 2009) 41 (Matuska and Christiansen, 2008)

10 (Eriksson et al., 2010) 26 (Wada and Beagan, 2006) 42 (Matuska et al., 2013)

11 (Eriksson et al., 2011) 27 (Wagman et al., 2012a) 43 (Pentland and McColl, 2008)

12 (Forhan and Backman, 2010) 28 (Wagman et al., 2012b) 44 (Piskur et al., 2002)

13 (Gibbs and Klinger, 2011) 29 (Westhorp, 2003) 45 (Reece et al., 2009)

14 (Hakansson et al., 2009) 30 (Wilcock, 1997) 46 (Wada et al., 2010)

15 (Hakansson et al., 2011) 31 (Wilson and Wilcock, 2005) 47 (Wagman et al., 2011)

16 (Jonsson and Persson, 2006) 32 (Argentzell et al., 2012)

LB: life balance; No.: number; OB: occupational balance.

Dur et al. 15