MASTER IN DE ERGOTHERAPEUTISCHE WETENSCHAP · 2015-11-06 · Academiejaar 2014-2015 MASTER IN DE...
Transcript of MASTER IN DE ERGOTHERAPEUTISCHE WETENSCHAP · 2015-11-06 · Academiejaar 2014-2015 MASTER IN DE...
Faculteit Geneeskunde en Gezondheidswetenschappen
Development, validity and reliability evidence
for the Flemish version of the Life Balance Inventory
in people with multiple sclerosis
-
Hélène Dirix
Masterproef ingediend tot
het verkrijgen van de graad van
Master of science in de ergotherapeutische wetenschap
Promotor: Prof. Dr. Daphne Kos
Copromotor: Sven Van Geel
Academiejaar 2014-2015
MASTER IN DE ERGOTHERAPEUTISCHE WETENSCHAP
Interuniversitaire master in samenwerking met:
UGent, KU Leuven, UHasselt, UAntwerpen,
Vives, HoGent, Arteveldehogeschool, AP Hogeschool Antwerpen,
HoWest, Odisee, PXL, Thomas More
Faculteit Geneeskunde en Gezondheidswetenschappen
Development, validity and reliability evidence
for the Flemish version of the Life Balance Inventory
in people with multiple sclerosis
-
Hélène Dirix
Masterproef ingediend tot
het verkrijgen van de graad van
Master of science in de ergotherapeutische wetenschap
Promotor: Prof. Dr. Daphne Kos
Copromotor: Sven Van Geel
Academiejaar 2014-2015
MASTER IN DE ERGOTHERAPEUTISCHE WETENSCHAP
Interuniversitaire master in samenwerking met:
UGent, KU Leuven, UHasselt, UAntwerpen,
Vives, HoGent, Arteveldehogeschool, AP Hogeschool Antwerpen,
HoWest, Odisee, PXL, Thomas More
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Abstract – Dutch
Doelstelling: Sinds het ontstaan van de discipline occupational science is balans al één
van de kernconcepten maar er zijn niet veel instrumenten beschikbaar die dit construct
meten. De Life Balance Inventory (LBI) werd vertaald naar het Nederlands. Mensen met
MS ervaren minder life balance in hun leven, dit maakt het interessant om te onderzoeken
of er betrouwbaarheids- en validiteitsevidentie gevonden kan worden omtrent de LBI en
personen met MS.
Methode: Dit is een kwantitatieve studie die de psychometrische kenmerken van de LBI
tracht te bepalen, 22 proefpersonen namen deel. Ze vulden elk twee maal de LBI in en bij
de eerste afname ook drie testen die gerelateerde concepten van life balance meten.
Resultaten: Er werd een hoge graad van test-hertest betrouwbaarheid gevonden (ICC:
0,641 – 0,904). De Cronbach’s alpha werd berekend en toonde een hoge interne
consistentie aan (α = 0,825). Er werden correlaties gevonden tussen de LBI en de
subschalen en de DASS-21 (r = -0,447 – -0,827) en de PWI-A (r = 0,374 – 0,694). Er
werden geen correlaties gevonden tussen de LBI en de BPNS. Een secundaire analyse
toonde ook geen verschillen binnen de demografische categorieën.
Conclusie: De gevonden evidentie in deze studie draagt bij tot de bruikbaarheid van de
Vlaamse versie van de Life Balance Inventory en het internationale onderzoek omtrent
de LBI en het LBM. Het gebruik van het concept life balance kan zo uitgroeien tot een
van de kernaspecten van ergotherapie in Vlaanderen.
Key words: ergotherapie, life balance, life balance inventory, multiple sclerose,
psychometrische kenmerken
Aantal woorden masterproef: 12.197 (exclusief inhoudstafel, bijlagen en bibliografie)
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Abstract – English
Objective: Balance is one of the core concepts since the beginning of occupational
science, but not many assessment instruments are available that measure this construct.
The Life Balance Inventory (LBI) was translated into the Flemish language. People with
MS experience lower levels of life balance, which makes it interesting to examine
whether or not reliability and validity evidence can be found regarding the LBI and MS-
patients.
Method: This study tries to determine the psychometric properties of the LBI, 22
participants participated. They all have to fill in the LBI twice and had to fill in three other
tests that measure related concepts of life balance during the first test moment.
Results: A high degree of test-retest reliability was found (ICC: 0,641 – 0,904). The
Cronbach’s alpha was calculated and showed a high internal consistence (α = 0,825).
Correlations were found between the LBI and its subscales and the DASS-21 (r = -0,447
– -0,827) and the PWI-A (r = 0,374 – 0,694). No correlations were found between the
LBI and the BPNS. Secondary analysis showed no difference within the different
demographical categories.
Conclusion: The results of this study contribute to the usefulness of the Flemish version
of the Life Balance Inventory and the international research regarding the LBI and LBM.
Using the construct of life balance in daily practice can become one of the core concepts
of occupational therapy in Flanders.
Key words: life balance, life balance inventory, multiple sclerosis, occupational therapy,
psychometric properties
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Table of Contents
Abstract – Dutch ............................................................................................................... 5
Abstract – English ............................................................................................................ 7
List of tables ................................................................................................................... 10
Acknowledgements ........................................................................................................ 11
1. Introduction .............................................................................................................. 13
2. Research question .................................................................................................... 27
3. Method ..................................................................................................................... 29
4. Results ...................................................................................................................... 37
5. Discussion ................................................................................................................ 45
6. Recommendations for further research .................................................................... 53
7. Conclusion ............................................................................................................... 55
References ...................................................................................................................... 57
Appendixes ..................................................................................................................... 67
Appendix 1: Search strategy review of literature ........................................................... 69
Appendix 2: Information letter ....................................................................................... 71
Appendix 3: Informed consent ....................................................................................... 75
Appendix 4: Life Balance Inventory (Flemish version) ................................................. 77
Appendix 5: Demographical questionnaire .................................................................... 81
Appendix 6: DASS-21 (Flemish version) ...................................................................... 83
Appendix 7: PWI-A (Flemish version) .......................................................................... 85
Appendix 8: BPNS (Flemish version) ............................................................................ 87
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List of tables
Table 1: Demographic characteristics…………………………………………………..37
Table 2: List of descriptives…………………………………………………………….39
Table 3: Correlation coefficients………………………………………………………..39
Table 4: Wilcoxon Signed Ranks Test results…………………………………………..40
Table 5: List of correlations.……………………………………………………………42
Table 6: Results of the Levene’s tests statistic and ANOVA……………………...…….43
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Acknowledgements
Finally, after two years of studying, the work is done! With proudness I present you my
thesis: ‘Development, validity and reliability study of the Flemish version of the Life
Balance Inventory in people with multiple sclerosis’.
The last two years haven’t been easy but I’ve learned a lot. It have been the most busy
years of my life and sometimes it wasn’t easy to achieve balance in my life. Due to this
master’s program, my vision as an occupational therapist is highly enriched. I feel like
I’m ready to step into the world as a full professional. I hope that my research can
contribute to the (further) development and research about the concept of life balance but
as well to the bigger picture of ‘occupational science’.
I would like to thank everyone for their support and trust in me, for some not only the last
couple of months but the last couple of years. I would like to thank the following people
in particular.
First, I would like to thank my promotor Dr. Daphne Kos. Thank you for all the help and
advice when I needed it, for always reading my text critically and giving feedback, for
starting the translation of the LBI and for making it possible to gather my data in the
National MS-Centre at Melsbroek.
Also thank you to my copromotor Sven Van Geel for giving me advice about the subject,
for starting the translation of the LBI and for proposing this subject as a master’s thesis
subject. It has been a pleasure to do something that I’m committed to.
I would like to thank the National MS-centre at Melsbroek for letting me gather my data
in their setting and the occupational therapy department for letting me use their therapy
hours to conduct my data. I thank Karen Verbeek in particular, she helped me finding the
participants and always helped when I was in need or had some questions.
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Of course I would like to thank all the participants, without you I couldn’t have done this
research. Thank you for letting my use some of your valuable time and for sharing all this
information with me.
A special thanks goes out to all of my friends and family. Thank you for listening to me,
for giving me advice, for your support and for always being there when I needed you!
They say ‘save the best for last’, so the last ones I’d like to thank are my mom and dad.
Thank you for always believing in me even when it didn’t seem like everything was going
to be all right. Thank you for giving me the chance to do all of this. Without you, I never
could have done what I did and I would never have achieved what I achieved the last
couple of years.
Thank you all, I hope you enjoy reading my thesis!
Hélène Dirix
3th of May 2015
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1. Introduction
1.1 Balance
The idea of a balanced life has existed for a long time. Hippocrates (c. 500 B.C.) said that
the balance of four humors was related to a healthy life. Galen (131 – 201) expanded this
idea, proposing that a balance of the ‘passions’ was essential for physical health
(Sternberg , 1997). Different disciplines have been interested in this concept for example:
sociologists are interested in the ways people seek their balance between the demands of
their work and family. Anthropologists want to know how cultures prescribe and limit
their roles and occupations (Westhorp, 2003). Other cultures, ranging from Chinese
medicine to Native American healing believe that health requires a balance among
thoughts, actions and feelings, and that the environment provides the people opportunities
and challenges for maintaining their well-being and for meeting their needs (Alter, 1999).
Occupational science is the field that is interested in balance. Occupational scientist are
interested in the ways humans use a variety of occupations to: meet the demands of their
culture and society, develop skills, achieve satisfaction and maintain healthy
(Christiansen & Mautska, 2006; Westhorp, 2003). The focus of occupational science is
how daily activities influence health and well-being (Larson & Zemke, 2003). Many
authors state that occupational balance can be one of the key concepts in the area in which
occupational therapists try to determine the relationship between engagement in
occupations and health (Christiansen & Matuska, 2006; Meyer, 1922/1977, Reilly, 1977).
People use occupations in order to achieve a sense of being the person they want to be,
as well to cope with the demands of their roles (Christiansen & Matuska, 2006). The
pressure to be capable and efficient, and respect for one’s values, needs and resources as
well, can affect engagement in occupations (Hakansson, Dahlin-Ivanoff & Sonn, 2006).
Balance has been one of the core concepts to develop a base of knowledge about human
occupation(s) since the beginning of occupational science (Christiansen, 1996). But the
concept of balance has a much larger history within occupational therapy. Meyer
(1922/1977), said that everyone needed a balance between the ‘big four’ – work and rest
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and play and sleep – (Westhorp, 2003). He did not mention anything about whether this
balance indicated equal amounts of time or not.
Since the concept of balance has been introduced, many have tried to describe this
concept. Popular media promotes the necessity to achieve: ‘balanced lives’ and ‘balanced
diets’. The time-pressure related to the modern life in western cultures have increased the
public interest of how life styles can be managed (Christiansen & Matuska, 2006). There
is a growing interest in developing an understanding, from an occupational perspective,
of the experience of life balance (Hakansson et al., 2006). Yet, 25 years later, there is no
consensus, definition, model or measure (Backman, 2004; Christiansen & Matuska, 2006;
Westhorp, 2003). Sheldon et al. (2010) suggest that it is almost impossible to define and
measure a concept with a theoretical weight that has been placed upon it from ancient
times to the present. But Wilcock et al. (1997) claim that an evaluation of a client’s
perceptions of their balance between all of their occupations in their present and future
lifestyle should become a part of standard occupational therapy-practice.
As noted earlier, the roots of balance within occupational therapy go back to Meyer
(1922/1977) but more recently many authors tried to explain and create a model to
understand and theorise the concept of balance. Christiansen (1996) claims in order to
achieve well-being work, leisure, self-maintenance, and sleep should be distributed
equally over the day. But the number of occupations and the amount of time spent in each
occupation does not have to be equal. Kielhofner (2002) states that balance in everyday
life would reflect a dynamic interconnection of the occupational domains and their
relationship to interests, internal values, and goals. He further claims that there is a
dynamic relation with the external demands of the environment as well. Westhorp (2003)
states that people undertake change in their occupations to achieve some kind of harmony
which can lead to states of calmness, mental steadiness, and improved health and well-
being. Pentland & McColl (2008) have another view on occupational balance, they state
that the concept doesn’t include the underlying choices that lead to occupations. The
underlying idea of life balance is living congruent with one’s personal meaning and
values. They call this ‘occupational integrity’.
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Christiansen and Matuska (2008, 2012a) proposed a model about balance: ‘the Life
Balance Model’. It builds on the research about the psychological and psychological
attributes that are considered important for well-being. The model also underlines the
importance of the interaction between the individual and the environment (Matuska,
2010).
Hakansson et al. (2006) suggest that there are four factors that influence each other, which
can either lead to balance or imbalance. Those four factors are: (1) Image of occupational
self, (2) Strategies to manage and control everyday life, (3) Occupational repertoire, and
(4) Occupational experience, this includes the participants’ own meaning and
interpretations of their daily occupations.
Stamm et al. (2009, p33) used the following definition: ‘occupational balance means to
be engaged in different types of occupations in a dynamic way so that this individual mix
of occupations leads to health and to high quality of life as experienced by the individual’.
They developed three dimensions of occupational balance: (1) Challenging versus
Relaxing Occupations and Activities, (2) Activities Meaningful for the Individual and
Activities Meaningful in a Sociocultural Context, (3) Activities Intended to Care for
Oneself and Activities Intended to Care for Others. They claimed that occupational
balance does not necessarily require being engaged in paid work but rather being engaged
in challenging activities and any kind of productivity (Stamm et al. 2009).
A more recent review of Wagman, Hakansson & Jonsson (2015) contained 22 articles
regarding occupational balance between 2009 and 2014. They found out that there is a
major geographic gap in the area where occupational balance is researched. Almost all
the publications were from Sweden and Canada. Their overall conclusion was that the
inclusion of occupations that are linked to people’s own interests and joy, seems to be
very important for experiencing occupational balance. An optimal variation within the
daily occupations is important as well. The authors stated that more research is needed
regarding the difference between occupational balance and life balance although they
wondered if there even is a difference. Sheldon, Cummings & Kamble (2010) did go even
further, they wondered if we need a theoretical construct of life balance. They asked
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themselves whether or not that there already is another name or phenomena that describes
the same?
Even though there is no consensus about life balance, many research has shown that
balance can have an influence on health and well-being, either positive or negative. It is
an important aspect of the health experience (Christiansen & Matuska, 2006; Hakansson,
et al., 2006; Hakansson, Lissner, Björkelund & Sonn, 2009; Wagman et al., 2015;
Wilcock et. al, 1997). Overall health seems to be influenced by engagement in
occupations (Canadian Association of Occupational Therapists, 1994). These findings
make it interesting for occupational therapists to use this as one of their core businesses.
Making people agents rather than victims of their daily lives is the role of meaningful
occupations (Hakansson et al., 2006).
As described above, there are multiple ways and models that describe some kind of
balance. This paper and research will be conducted on the basis of the Life Balance Model
and the Life Balance Inventory from Matuska and Christiansen.
1.2 The Life Balance Model (LBM) & Life Balance Inventory (LBI)
1.2.1 Life Balance Model (LBM)
The LBM is a theoretical model that supports the concept of life balance and imbalance
by Matuska and Christiansen (2008). It has been developed on interdisciplinary research
about the psychological and psychological attributes that are considered important for
well-being (Christiansen & Matuska, 2006). It was created upon the theories of Maslow
(1943), Ryff (1995), Ryff & Singer (1996) and the Self Determination Theory from Deci
& Ryan (2000) (Matuska & Christiansen, 2008). The model suggests that certain
configurations are considered balanced or imbalanced depending on whether the needs of
a person are met (Matuska, 2010; Matuska, 2012a).
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The model describes life balance as: ‘A satisfying pattern of daily activity that is healthful,
meaningful, and sustainable to an individual within the context of his or her current life
circumstances’ (Matuska & Christiansen, 2008, p. 11).
Satisfying: the amount actually spent on participating in activities and the amount
of time one would like to spend is equally distributed;
Healthful: activities contribute to both psychological and mental health;
Meaningful: activities engaged in are important;
Sustainable: activity configurations can be maintained over a long term (Matuska,
2010).
Life balance is expected to relate to lower stress, higher need satisfaction and higher
personal well-being. The model suggests that people who participate in activities that
meet all of the need-based dimensions will perceive their lives as less stressful, more
satisfying, and more balanced (Matuska, 2012b).
In order to engage in everyday activities activity configurations are required. The model
suggests that all these activities should help people to: (1) meet basic instrumental needs
necessary for sustained biological health and physical safety; (2) have rewarding and self-
affirming relationships with others; (3) feel engaged, challenged, and competent; (4)
create meaning and positive identity (Matuska & Christiansen, 2008). There is also a fifth
need-based dimensions: (5) to organize their time and energy in ways that enable them to
meet important personal goals and renewal. Time and energy are viewed as the key
dimensions in the model because they contribute to the creation of meaning (Matuska,
2010).
The balance part of the model focuses on ‘activity configurations’ which means that there
should be an equal proportion of satisfaction with time use across various activities that
meet the model’s four need-based dimensions (Matuska, 2012a). The activity
configurations are divided into two components: ‘activity configuration congruence’ and
‘activity configuration equivalence’. There is an overlap between these two because both
are necessary for a balanced life (Matuska & Christiansen, 2008). Congruence means that
one’s actual activity configurations matches one’s desired activity configurations.
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Equivalence allows people to meet the four need-based dimensions through their activity
configurations. High equivalence means that there is an equal proportion of time use
(congruence) across various activities that meet the need-based dimensions of the LBM
(Matuska, 2010). The activity configurations vary for individuals across situations and
time because people have different roles and role requirements in different situations
(Matuska, 2012a; Matuska, 2012b).
The model suggests that there is an environmental context as well. This context includes:
the physical, social, cultural, political and economic, and temporal context. The
interaction between the person and his or hers environment is dynamic (Matuska &
Christiansen, 2009). See figure 1 for a visual representation of the Life Balance Model.
Figure 1: The Life Balance Model (Matuska, 2010)
When people can experience life balance, there is always the possibility to experience life
imbalance. The model describes this as a configuration of daily activities that do not
satisfy the individual and which: (1) increase the risk for both physical and mental health
problems, (2) limit or compromise participation in valued relationships, (3) do not
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establish or maintain a satisfactory identity, (4) are felt to be boring, uninteresting or
unchallenging, (5) or are not enough organized to enable goals achievement or self-
renewal (Matuska, 2009; Matuska & Christiansen, 2009).
1.2.2 Life Balance Inventory (LBI)
After the Life Balance Model (LBM) was created, the LBI was created, it can be used for
research, but also for personal assessment of life balance that could inform individuals
about the balances and imbalances in their lives (Matuska, 2010; Matuska, 2012a).
This assessment contains 53 items that represent the range of activities in which people
in western cultures can engage (Matuska, 2012a). It tries to capture how individuals meet
their needs through daily activity configurations (Matuska, 2010). It is built to measure
congruence (mean score across all items respondents do or want to do) and equivalence
(mean scores of the subscales) (Matuska, 2010; Matuska, 2012b). The author used the
basic categories of daily living: instrumental activities of daily living, work, rest, play,
education, leisure, and social participation for creating the activity categories. There were
three important principles that guided the development of the LBI:
The configurations of daily activities are unique to each person;
Imbalance can result from spending too little or too much time in one or more
activities;
The activity categories in the scale reflect the need-based dimensions of the LBM
(Matuska, 2012b).
The LBI contains four subscales that are linked to the need-based dimensions of the LBM:
(1) Health subscale (ex. Relaxing, getting regular exercise, …), (2) Relationship subscale
(ex. Doing things with friends, partner, …), (3) Identity subscale (ex. Taking care of your
appearance, participating in religious events, …), (4) Challenge/interest subscale (ex.
Working for pay, making music, …) (Matuska, 2010).
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The instrument contains 53 activities and on a dichotomous scale of yes/no, people have
to answer, whether or not they do the activity or want to do the activity. For each item
that they scored ‘yes’, they have to rate their satisfaction with the amount of time they
have spent doing that activity in the past month compared to the amount of time they
wanted to do the activity. The possible answers are: “always less than I want, sometimes
less than I want, about right for me, sometimes more than I want, always more than I
want” (Matuska, 2010; Matuska, 2012a). This scoring method makes it possible to
individualizes the results to reflect the unique activity configuration of each individual.
The satisfaction rating reflects the fifth dimension of the LBM (Matuska, 2010).
1.2.3 Evidence regarding the Life Balance Model and the Life Balance Inventory
The articles described in this section are the ones that either involve the LBM, the LBI or
both. Most of the research has been conducted in Sweden or the United States (Hakansson
& Matuska, 2010; Matuska, 2012b; Matuska, Bass & Schmitt, 2013; Matuska &
Erickson, 2008; Stein, Foran & Cermak, 2011; Wagman, Hakansson, Matuska, Björklund
& Falkmer, 2012). The concept of life balance have been examined within different
groups: women with MS (Matuska & Erickson, 2008), the American population
(Matuska, 2012a; Matuska, 2012b; Matuska et al. 2013), the working Swedish population
(Wagman et al., 2012), Swedish women with a stress-related disorder (Hakansson &
Matuska, 2010), and parents of children with autism (Stein et al., 2011). All of the studies
provided validity evidence for either the LBM, the LBI or both, yet some differences were
found between the groups.
Matuska & Erickson (2008) explored how women with MS experience their disease and
how they feel about their lifestyle balance. Participants said that life balance is a
continuous challenge, they have to make frequent adaptations in their lifestyle and/or
physical and social environments. People with MS constantly have to make choices
whether they an activity or not because doing multiple activities would be too hard and
tiresome. Mostly they would do the occupations that they considered necessary and did
not always have energy left to meet their other needs. Dimension 5, was seen as an
overwhelming challenge because of their severe fatigue. Yet, the participants could relate
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to all five of the need-based dimensions and so this provided validity evidence for the
LBM. The same results were found in a study with Swedish women recovering from a
stress-related disorder (Hakansson & Matuska, 2010). Participants felt like they were
always balancing between a balanced and imbalanced life. They became more ill when
they experienced more stress and anxiety due to their imbalanced life. All of the need-
based dimensions influenced their balance but also felt like the fifth dimension of the
LBM was the most challenging. In contrast to the women with MS they felt like they
regained control over the occupations that were most important when they made active
choices about how to spend their time and energy.
Both studies described above have recruited female participants with a health condition.
Yet, the Life Balance model should also be applicable to the general population. Wagman
et al. (2012) interviewed 19 participants from the general Swedish population on their
perception of life balance and the LBM. The participants reported that each need-based
dimensions was important for their life balance, health and well-being. While they related
imbalance to ill-being, the participants indicated that there was an additional dimension
that was not reported in the LBM: financial security. They said that financial security can
be contribute to and/or affect life balance.
Stein et al. (2011) used the LBM in order understand the life experiences of parents of
children with autism spectrum disorder. They concluded that the LBM could be a good
way to describe life balance but suggested a refinement of the model because of the
complex relationships between the five dimensions. The authors concluded that some
dimensions were difficult to separate as some constructs appeared to overlap in the
autism-population.
After creating the LBM and the LBI, Matuska (2012b) conducted two quantitative studies
to test the validity of both the model and the measure. Matuska (2012b) conducted no
separate study to determine the validity of the LBM. She claimed that the model would
automatically gain validity evidence when the results of the reliability and validity study
of the LBI were good. This because the LBI is created upon the constructs of the LBM,
thus the constructs of the LBM would be validated as well by only validating the test.
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The pilot test included 282 people (90% women); the analysis showed that the items of
the LBI captured a wide range of activities and that the items fit with the LBM. The
second study included 458 participants who had to complete the LBI together with the
Depression Anxiety Stress Scales-21 (to measure perceived stress), Personal Wellbeing
Index-Adult (to measure quality of life and well-being), the Basic Psychological Needs
Scale (to measure the level of competence, autonomy, and relatedness) and a
demographic questionnaire. The results showed that:
Congruence is positively associated with personal well-being (r = .49), and basic
psychological need satisfaction (r = .62), competence (r = .67), and autonomy (r
= .86). Congruence was negatively related with stress (r = -.40).
The equivalence part of model is not as favourable as the congruence part of the
model.
Equivalence showed to be significantly related to congruence but not to the other
variables. A fit of the congruence and equivalence model seemed the best fit.
A secondary analysis was drawn from the online database with completed surveys of the
LBI by Matuska et al. (2013) to see which demographic profile had the highest life
balance and to see if life balance predicted perceived stress. Results showed that the
profile with the highest life balance was: white, 61 years or older, had a master’s degree,
lived in the suburbs, had two children, was not working, owned a home and lived in the
United States. They also stated that females had significantly lower LBI Identity subscale
scores and significantly higher stress scores than males. Further analysis showed that
higher life balance scores predicted lower perceived stress scores.
1.3 Other assessment regarding balance
Apart from the LBI, very limited assessment instruments regarding balance are available.
It is difficult to capture a construct that has no general definition in a measure. More
recently, three measurements have been developed and tested: the Meaningful Activity
Wants and Needs Assessment (MANWA) (Eakman, 2015), the Occupational Balance
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Questionnaire (OBQ) (Wagman & Hakansson, 2014) and the Occupational Balance-
Questionnaire (OB-Quest) (Dür, et al., 2014).
The Occupational Balance Questionnaire (OBQ) is an instrument that measures
occupational balance. The conceptual framework for this instrument is based on results
from previous research regarding balance. The instrument focuses on the variation in the
occupational patterns, the meaningfulness in the occupations and the amount of each
occupation and the total amount of occupations in relation to the available ones. The
authors state that all these aspects are necessary to experience occupational balance
(Wagman & Hakansson, 2014). The OBQ consists of 13 items, each one is measured on
a six-step ordinal scale, ranging from completely disagree to completely agree. Because
this assessment does not specify the occupations, it may also overcome cultural
differences. The OBQ has good internal consistency, no floor or ceiling effects, all items
were stable and had a kappa coefficient below 0.60 and test-retest reliability was
sufficiently stable as well (Wagman & Hakansson, 2014).
The Occupational Balance-Questionnaire (OB-Quest) by Dürr, et al. (2014) is a self-
report instrument that consist of ten questions regarding occupational balance. Eight
components of occupational balance were used as a basis for the questionnaire. Each
question has three possible answers and the scores range between one and three.
Researchers found a good internal consistency, but they claimed that occupational
balance might be a multidimensional construct that is hard to capture within one
assessment.
The Meaningful Activity Wants and Needs Assessment (MANWA) from Eakman (2015)
consists of 21 items and taps a need for meaningful occupations. It proposes a new
definition of life balance so that persons can evaluate their ongoing occupations as
meaningful although they are currently not perceiving a need for more meaning in their
occupations. When a person is balanced, he or she will experience higher levels of
meaningful occupations and lower levels of perceived need for meaningful occupations.
The items from the MANWA are created upon items from validated measures of related
constructs such as meaningful occupation and occupational value. The assessment should
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be capable of generating a score that reflects a person’s perceived need for meaningful
occupation. The MANWA shows very good internal consistency and test-retest
reliability, discriminant and convergent validity have been identified through its
correlation with both meaningful activity and indicators of well-being.
1.4 Multiple sclerosis, stress and well-being
Multiple sclerosis is an autoimmune demyelating disease of the central nervous system,
characterized by inflammation. The origin is unknown and it has an unpredictable course.
It is a progressive disease with a relapsing-remitting pattern (Casetta & Graniere, 2000).
The immune system attacks the brain and spinal cord causing lesions, this lesions can
either be silent or may cause a neurological deficit (Rapaport & Karceski, 2012). The
treatment of MS is mainly focused on the reduction of relapses, symptom and disability
relief (Artemiadis et al., 2012; Bruck, 2000; Karagkouni, Alevizos & Theoharides, 2013).
There is a well-established relationship between stress and MS. Stressors lead to
symptoms of anxiety and depression and this compromises their quality of life
(Artemiadis et al., 2012). Emotional stress can be linked with the exacerbation of
neurological symptoms (Artemiadis et al. 2011; Heesen et al., 2007). Studies show that a
long exposure to challenging life events is correlated with worsening neurological
symptoms and an increased number of lesions (Lovera & Reza, 2013; Mitsonis, Potages,
Zervas & Sfagos, 2009). Research suggests that reducing stress could help people with
MS to cope with and adjust to their disease (Artemiadis et al., 2012).
Compared to other chronic diseases, MS is considered as the most threatening to
psychological well-being (Bassi et al., 2014; Rudick, Miller, Clough, Gragg & Farmer,
1992), they experience a rather low well-being and high ill-being (Bassi et al., 2014).
Evidence suggests that people with MS are more sedentary than the general population
and that there is a positive effect on their well-being when they engage in more physical
exercises (Mc Auley, Motl, Morris, Doerksen, Elavsky & Konopack, 2007). Patients who
experience cognitive changes have a greater disturbance in performing activities of daily
25
living and are less likely to engage in social activities. This has an impact on their well-
being in general (Hakim, Bakheit, Bryant, Roberts, McIntosh, Spackman et al., 2000;
Shevil & Finlayson, 2006). Between 70 and 90 percent of the people with MS report
fatigue as one of the most annoying symptoms of MS (Béthoux, 2006). The fatigues has
a major impact on their lives and most of the people who experience fatigue conduct less
activities which results in less quality of life (Amato, Ponziani, Rossi, Liedl, Stefanile &
Rossi, 2001; Janardhan & Bakshi,2002). Fatigue has also been linked to depression,
Kroencke et al. (2003) suggested that depression and fatigue were highly correlated.
Research suggests that when people with MS engage in meaningful leisure pursuits, their
general satisfaction with life is increased (Hakim et al., 2000). Reynolds and Prior (2003)
state that taking care of their health, maintaining meaningful occupations and roles,
establishing mutual relationships, clarifying beliefs and valuing positive life experiences,
increased the quality of life of women with MS.
As described above, life balance is a construct with no consensus but is one of the core
concepts of occupational science. There are also not many assessment instruments
available to measure balance within the patient populations. None of the little amount of
assessments that is available is translated into the Flemish/Dutch language. It can be a
giant step forward for occupational therapists to have an instrument that measures balance
and use it within the field of the occupational therapy practice in Flanders. That’s why
there has been chosen to translate the LBI. People with MS are a good population to verify
the LBI because a lot of people with MS experience fatigue and can conduct less activities
of daily life which result in less quality of life (Amato, Ponziani, Rossi, Liedl, Stefanile
& Rossi, 2001; Janardhan & Bakshi,2002). Life balance is negatively related with stress
and positively related with well-being and health (Matuska, 2012b). Thus, when people
with MS can achieve higher levels of Life Balance, there is assumed that their stress level
will be decreased and they will experience more well-being and have a greater health
sense (Matuska & Christiansen, 2008). Using the LBI could help occupational therapists
in their practice with people with MS (Matuska & Christiansen, 2008).
See appendix 1 for the search strategy of this review of the literature.
27
2. Research question
As described in the introduction, there is no consensus regarding life balance and not
many assessment instruments are available. There are no instrument that measure the
construct of life balance in Flemish and so there has been chosen to translate the LBI.
Before using the LBI in our daily practice, the assessment has to be tested to make sure
the measurement measures the construct of life balance. There is some empirical evidence
about life balance and people with MS and there’s also evidence about the related
concepts of the LBM and LBI like well-being, stress and need-satisfaction by people with
MS. Because of this, there has been chosen to test the LBI by people with MS.
Following research question is proposed:
‘Is the Life Balance Inventory (Flemish version) a valid and reliable instrument to
measure the construct of life balance in people with multiple sclerosis who live at home?’
Following sub questions (and hypotheses) are proposed:
Do the overall scores of LBI, after waiting for at least one week, have the same
results as the first time?
Do all the subscales of the LBI have the same result, after waiting for at least on
week, as the first time?
Do all the items of the LBI contribute equally to the whole?
Does overall congruence (total score on the LBI) relate to less stress, higher well-
being, and higher need satisfaction?
Do the scores of each subscale individually relate to less stress, higher well-being
and higher need satisfaction?
Is there a relation between the LBI-scores and the demographic data?
Is there a difference in the total score of the LBI within the different demographic
categories (gender, marital status, years of MS, work situation and education)?
29
3. Method
3.1 Translating process
Before starting the quantitative research, the LBI needed to be translated into the Flemish
language. The following steps are conducted as proposed by Kielhofner (2006):
Translating to the target language: All of the items of the LBI have been translated
into the Flemish language after discussing how to formulate each item.
Consensus: Six people who had nothing to do with the study have indicated what
their thoughts were on every item. After they gave their meaning, all the results
were compared to find a consensus. The item is adapted if necessary in case of
disagreement.
Independent retranslation: Another independent person have translated the
Flemish version of LBI back into English. This has been done to make sure that
the items were still the same as in the original version. After this, the retranslated
test was sent to the original author.
Revision (if needed): If needed, some items would have been adapted. No items
needed a revision so this step has not been conducted.
Validity and reliability: The last step of the process is this study, checking for
validity and reliability evidence.
3.2 Research design
This is a non-experimental, observational, cross-sectional design looking for relationships
among variables at a given moment in time. Within this quantitative research, the
following items will be measured:
Construct validity: Kielhofner (2006) states that when an instrument tries to
describe and/or evaluate the content and construct validity should be examined.
Due to the short period in which the study has to be finished, there has been chosen
to only examine the construct validity. Fawcett (2007) states that when there is no
golden standard, construct validity must be measured instead of criterion validity.
30
The validity will be measured by calculating relationships between the LBI and
other assessments.
Test-retest reliability: As stated in the translation process, both the validity and
the reliability have to be tested. When an instrument evaluates it is important that
the results or consistent over time (Fawcett, 2007).
Internal consistence: An instrument should be as short as possible but still have
the same result as a long version. Because of this the internal consistence should
be examined, to check whether all of the items contribute equally to the test. If
some items contribute less than others perhaps they can/should be removed
(Kielhofner, 2006).
Correlations between the demographic data and the LBI: these items do not
validate or test the reliability of the LBI. This is a secondary analysis to draw
further conclusion about whether some profiles experiences more are less balance
then others (Matuska, 2010; Matuska, 2013).
3.3 Sampling
The participants have been recruited in the National MS-centrum at Melsbroek, Belgium.
This is one of the largest hospitals in Belgium for people with MS and other neurological
diseases. People can have both residential care and non-residential care where they come
in at morning or noon, receive their therapy and go back home (MS-Centrum, 2015). The
people who visit the outpatient clinic are the ones that can tell what balance is, people
who have experienced disbalance but have found some kind of balance now, are the ones
that can describe what balance exactly is for them (Stamm, 2009).
3.4 Operationalization
At least 20 persons were necessary to conduct the research. Otherwise there wouldn’t be
enough power and so the study would have no value (Portney & Watkins, 2014). The
participants have been selected on the basis of the inclusion and exclusion criteria as
31
described below. One of the occupational therapists in the centre selected the people that
fit the profile to participate in the study and who were likely to participate.
The participants had to meet the following conditions (inclusion criteria):
Adults, 18 – 65 years old;
Diagnosed with multiple sclerosis;
Living at home: people who visit the centre for one to three times a week have the
possibility to link the assessment to their home situation.
In social hospitalization: those people don’t have a relapse, they come in to
unburden their caregivers or to put their treatment on point. Those people also
have the possibility to link the assessment to their home situation.
Participants who met one of the following conditions were excluded (exclusion criteria):
In hospitalization: people who have a (major) relapse their idea of life balance
will be influenced both by the disease and by the revalidation setting they are
currently living in. A stable situation is necessary for the test-retest reliability.
Cognitive impairments: people who have a score of less than three on Rao’s Brief
Repeatable Battery of Neuropsychological Tests (BRB-N) (Brooks, Borela &
Fragoso, 2011) are excluded because some cognitive capacity is necessary to
understand the items/questions of the assessments. This test is administered
standard in the MS-centre.
At the start of this study, 15 participants were approached. Expect for one, they were all
willing to participate. While testing the first 15 participants, others that fit the profile were
addressed to make sure that there were enough participants. Later on, seven more people
have participated in the study. This makes a total of 22 participants, which means that the
goal of 20 participants was reached. All the participants have been tested twice within
two or three weeks with a pause of at least one week to make sure that there were no
recall-biases but much longer wasn’t favourable as well because of the changeable
character of their disease (Fawcett, 2007).
32
3.5 Data-gathering
The data-gathering took place at the National MS-centre at Melsbroek. People have to be
in a stable position when testing the test-retest reliability, as pointed out in the review of
the literature, a relapse or worsening of their disease does affect their well-being, stress
level and need satisfaction which automatically has an influence on their balance
(Matuska & Erickson, 2008; Bassi et al., 2014).
Both of the times the participants had to fill in a list with personal information like
whether they are married or not, how long they have MS, how many children they have,
… This information can be used later on to establish a profile of the average participant.
They also had to indicate whether are not they have a preferential tariff, this means that
they have to pay less for their medical care because they don’t have the resources to pay
the full price. This question is asked to have a better view together with the employment
status, on the patients financial situation. The participants had to fill in the EQ-5D as well,
this is a five-question assessment instrument that helps people indicate how good or bad
their health and quality of life is. It measures: mobility, self-care, daily activities, pain
and depression, participants have the following possible answers: (1) no problems at all;
(2) moderate problems or (3) serious problems (Lamers, Stalmeier, McDonnell, Krabbe
& Busschbach, 2005). This instrument was used to measure if the participants had some
major health changes in the past week, when 3 or more items had changed in comparison
with the first testing, people were excluded from the study.
The first time when they filled in the LBI, the participants had to fill in other
measurements as well to check the construct-validity of the LBI. Those instruments were:
The Depression Anxiety Stress Scales (DASS-21) stress subscale: This instrument
is a rather short instrument that measures stress and has good psychometric
properties. It contains seven items about stress and the participants have to answer
whether or not the statements are: non-applicable, almost never applicable,
sometimes applicable or always applicable. This instrument has been translated
into Dutch and has been tested on internal consistence and validity (de Beurs, Van
Dyck, Marquenie, Lange & Blonk, 2011). The scores of this instrument are
33
normal distributed (Henry & Crawford, 2005). This instrument is used because it
is assumed that life balance correlates negatively with stress.
The Personal Well-Being Index-adult (PWI-A): This instrument measures the
quality of life and the well-being of a person. On a scale from zero to ten, people
have to indicate how satisfied they feel with several items, the results of this test
are normal distributed (International Wellbeing Group, 2013). This instrument is
also translated into Dutch and has been validated and tested for reliability (Van
Beuningen & De Jonge, 2011). This instrument is used because it is assumed that
life balance correlates positively with well-being.
The Basic Psychological Needs Scale (BPNS): This instrument measures the
extent to which people are satisfied with their autonomy, competence and their
relationships (Vlachopoulos & Michailidou, 2006). The scores of this instrument
are normal distributed (Chen, Van Assche, Vansteenkisten, Soenens & Beyers,
2014). Matuska (2012b) used this instrument to validate the LBI because this
instrument is based upon the Self Determination Theory of Deci & Ryan (2000).
There is no similar instrument in Dutch, this is a gap in the validation of the LBI.
For further research, the BPNS has been translated into Flemish but has not been
validated or tested on reliability. This instrument is used because it is assumed
that life balance correlates positively with need-satisfaction.
3.6 Data-analysis
The data-analysis started with entering all the results into an Excel-file. Both the total
scores as the mean scores were calculated, on person-level as well as on group-level.
Means, standard deviations, ranges, … were calculated to compare the results from to
participants.
After entering the data on to the computer the statistical processing started. This has been
done on the basis of SPSS with a significance level of p = 0,05. The process has been led
on the basis of the hypotheses proposed in section of the research question.
34
The following actions have been conducted:
Test-retest reliability: The difference between the first and second testing has been
measured. First the correlation between the first and second testing has been tested
by the Pearson Product-Moment Correlation coefficient (Portney & Watkins,
2014). Yet this isn’t the most reliable method because this cannot detect
systematic error (Weir, 2005; McGraw & Wong, 1996). To make sure that no
systematic or random error interfered in the result, the intra-class correlation
(ICC) (and concomitant ANOVA) have been conducted using a two-way random
model and type consistency. This was chosen because it detects both the
systematic and random error. In this model the rater and subject are random
effects, it is assumed that the results can be generalized (Portney & Watkins,
2015). A score of 0,70 or more on the ICC indicates a good test-retest reliability
(Terwee et al., 2007).
Internal consistence: By using Cronbach’s alpha there has been measured if all
the items contributed equally to the test. Terwee et al. (2007) state that in order to
have a good internal consistence, the minimal score should be at least 0,70.
Construct validity and overall congruence: Correlations have been calculated
between the LBI and the DASS-21, the BPNS and the PWI-A by using the Pearson
correlation coefficient. There have been tested parametric because the all the
assessments scores have a normal distribution. Each subscale of the LBI was
tested as well, the correlations between each subscale and the DASS-21, the BPNS
and the PWI-A were calculated by using the Pearson correlation coefficient.
Relationship between the overall LBI scores and the demographic data: To check
the difference between the gender, an independent t-test was conducted. This test
has been chosen because it calculates whether there is a difference between the
mean score of each group (Portney & Watkins, 2014). For the other variables,
one-way ANOVA’s have been conducted because the independent t-test can only
measure 2 groups and these categories had 3 or more groups. This test also
compares the mean score of each group and sees if there are significant differences
(Portney & Watkins, 2014).
35
3.7 Ethical considerations
All participants are fully informed about the study and the ethical considerations that go
along with it. They have had an information letter and had at least one week to think about
their participation in the study. They voluntarily agreed to participate and all the
participants of the study have signed a consent form. The information letter and the
consent form can be consulted in the appendix. The ethical commission of the National
MS-centrum Melsbroek has approved the study.
37
4. Results
4.1 General information / demographic data
A total of 22 participants participated in this study and all the testings were conducted in
the outpatient clinic of the National MS-centre Melsbroek. They should represent the
population of people with MS who live at home and are receiving ambulant therapy.
Approximately 64% of the participants were female and 36% were male and the mean
age was 56 years old (see table 1 for a full list of the characteristics).
Table 1: Demographic characteristics
Age:
18 – 30 years
31 – 50 years
51 – 65 years
Total:
N
1
4
17
22
%
4,5
18,2
77,3
100
Gender
Female
Male
Total:
N
14
8
22
%
63,6
36,4
100
Marital status
Single
Married
Divorced
Widowed
Total:
N
5
13
3
1
22
%
22,7
59,2
13,6
4,5
100
Preferential tariff
Yes
No
Total:
N
20
2
22
%
90,9
9,1
100
38
Number of children
0
1
2
3 or more
Total:
N
9
4
4
5
22
%
40,9
18,2
18,2
22,7
100
Number of children living with you:
0
1
2 or more
Total:
N
21
1
0
22
%
95,5
4,5
0,0
100
Employment status
Working
Disabled
Retired
Total:
N
1
18
3
22
%
4,5
81,9
13,6
100
Education level
Secondary education: 1st cycle
Secondary education 2nd or 3the cycle
Bachelor degree
Master degree
Total:
N
7
10
2
3
22
%
31,8
45,4
9,1
13,6
100
The overall scores on the life balance inventory ranged from 1,48 to 2,81 with a mean of
2,33 and had a standard deviation (SD) of 0,32. The health subscale had the highest mean
score of all the subscales (mean = 2,38). The lowest mean scores were derived from the
relationship and challenge subscales (mean = 2,32) (See table 2 for a full list of the
descriptives).
39
Table 2: List of descriptive
N Minimum Maximum Mean Standard
deviation
Scale
range
LBI 22 1,48 2,81 2,3323 0,32370 1 – 3
Health subscale 22 1,67 3,00 2,3805 0,36027 1 – 3
Identity subscale 22 1,33 3,00 2,3623 0,40081 1 – 3
Challenge
subscale
22 1,27 2,88 2,3200 0,44570 1 – 3
Relationship
subscale
22 1,33 2,83 2,3186 0,33194 1 – 3
PWI-A 22 17 76 54,409 12,9418 0 – 90
DASS21 22 1 20 6,318 4,6740 0 – 21
BPNS 22 79 123 105,091 12,9464 21 - 147
4.2 Reliability
4.2.1 Test-retest reliability
The correlation between the first and the second measurement was calculated using the
Pearson product-moment correlation coefficient. A significant correlation between the
two tests was found (r = 0,934) on a significance level of p = 0,01. All of the subscales
showed significant correlations as well (See table 3 for all the correlation coefficients).
Table 3: Correlation coefficients
Correlation
Coefficient
Significance
(2-tailed)
LBI 1 – LBI 2 0,934 0,000
Health 1 – Health 2 0,657 0,001
Identity 1 – Identity 2 0,646 0,001
Challenge 1 – Challenge 2 0,885 0,000
Relationship 1 – Relationship 2 0,781 0,000
40
Because the Pearson Product-Moment Correlation Coefficient can’t detect systematic
error, the intraclass correlation coefficient (ICC) was calculated using a two factor mixed
effects model and type consistency.
First, an analysis of variance (ANOVA) was calculated to see if there were no differences
between the two trials. There was no difference between the first and second test moment
(F(1,21) = 0,739, p = 0,40). A high degree of consistency was found between the both
tests, the single measure ICC was 0,904 (p < 0,05) with a 95% confidence interval from
0,784 – 0,959.
These tests (ANOVA and ICC) have also been conducted onto all of the subscales from
the Life Balance Inventory. No differences between the two trials were found in all of the
four subscales. The health and identity subscale had a moderate degree of reliability (ICC
= 0,641 & ICC = 0,642), the relationship and challenge subscale had a high degree of
reliability (ICC = 0,710 & ICC = 0,881) (See table 5 for the ICC test results).
Table 4: ICC test results
Intraclass
correlation
(single
measure)
95% Confidence Interval F Test
Lower Bound Upper Bound Significance
LBI 1 – LBI 2 0,904 0,784 0,959 0,000
Health 1 & 2 0,641 0,310 0,834 0,000
Identity 1 & 2 0,642 0,311 0,834 0,000
Challenge 1 & 2 0,881 0,735 0,949 0,000
Relationship 1 &2 0,710 0,420 0,869 0,000
41
4.2.2 Internal Consistence
The Cronbach’s alpha based on standardized items in this sample was 0,825 which is a
good Cronbach’s alpha (Portney & Watkins, 2014; Terwee et al., 2007). A second
analysis was conducted to see all of the Cronbach’s alpha scores if each of the items was
deleted, yet none of the items had a larger influence than 0,013 if they were deleted thus
no items should be deleted.
4.3 Construct validity
4.3.1 Correlation between the overall scores and the DASS-21, the PWI-A, and the
BPNS
For measuring the construct validity of the Life Balance Inventory, correlations between
the LBI and other assessment have been examined. The following results are derived from
the statistical calculations, see table 7 for a full list of the correlations:
The Life Balance Inventory has a significant high negative correlation with the
DASS-21 (r = -0,827, p = 0,000) meaning that when a person has an increased life
balance score, he or she reports less stress levels or visa-versa.
The Life Balance Inventory has a significant high positive correlation with the
PWI-A (r = 0,694, p = 0,000) meaning that with an increase in the life balance
score, well-being increases or visa-versa.
No significant correlations were found between the life balance inventory and the
BPNS on a significance level (p = 0,332) meaning that when a person has
increased life balance, he or she does not necessarily reports a higher need
satisfaction.
42
4.3.2 Correlations between the subscale scores and the DASS-21, the PWI-A and
the BPNS
Second, the correlations between each subscale and the DASS-21, PWI-A and the BPNS
were calculated to see if each subscale has an influence on health, well-being or need
satisfaction. The following results were derived from the analysis, see table 7 for a list of
all the correlations:
None of the subscale correlated significant with the Basic Psychological Needs
Scale meaning that when a person has a higher balance score on the health,
identity, challenge or relationship subscale, he or she does not necessarily
experience a higher need satisfaction.
The relationship subscale did not have a significant correlation with the PWI-A
(p = 0,087). All of the other subscales did correlate with the PWI-A and all of the
subscales correlated with the DASS-21 as well.
Table 5: List of correlations
DASS-21 PWI-A BPNS
Correlation
coefficient
Sign.
Level
(2-
tailed)
Correlation
coefficient
Sign.
Level
(2-
tailed)
Correlation
coefficient
Sign.
Level
(2-
tailed)
LBI -0,827 0,000 0,694 0,000 0,217 0,332
Health -0,447 0,037 0,430 0,046 0,098 0,664
Identity -0,797 0,000 0,667 0,001 0,268 0,228
Challenge -0,739 0,000 0,661 0,001 0,138 0,541
Relationship -0,707 0,000 0,374 0,087 0,224 0,316
DASS-21: Depression Anxiety Stress Scale 21
PWI-A: Personal Wellbeing Index-Adult
BPNS: Basic Psychological Needs Scale
43
4.4 Secondary analyses
A secondary analysis was performed to give some additional information about the
relationship between demographic and clinical data (gender, marital status, years of MS,
work situation, and education) and life balance. The results are listed below.
No significant difference within the LBI-scores was found between men and women (p =
0,486).
The relations between the other categories and the overall score on the Life Balance
Inventory were examined by using one-way ANOVA. A significant difference in variance
between the subcategories was found for the category ‘years of MS’ but the ANOVA-
results showed that there was no significant difference between the means. No significant
differences in the overall LBI score were found within the different categories of marital
status, years of MS, work situation and education (Table 8).
Table 6: Results of the Levene’s statistic and ANOVA
Levene
statistic
Significance ANOVA
significance
Marital status 1,057 0,368 0,932
Years of MS 3,816 0,043 0,932
Work situation 0,572 0,459 0,059
Education 2,092 0,137 0,531
45
5. Discussion
The test-retest reliability, internal consistence and construct validity of the Life Balance
Inventory were the primary focuses of this research. The results of the study gained
evidence for the test-retest reliability, internal consistence and construct validity for the
Flemish version of the LBI. In the following sections a critical approach towards the
results and methodology will be made.
5.1 General information/demographic data
People with MS indicate that each day is difficult because they always have to make
choices whether or not they will do an activity because of their fatigue (Matuska &
Erickson, 2008). Moreover, a more recent study of Wagman et al. (2013) showed that ill-
being is related to a lower overall score on the LBI. Despite of these findings, the overall
scores of the participants were rather high (mean score = 2,34). The mean scores on the
LBI and it subscales in study of Matuska (2010) ranged from 2,22 to 2,38 which are the
same results as this study however evidence suggest that people with MS experience less
health and well-being and more stress (Bassi et al., 2014; Rudick, Miller, Clough, Gragg
& Farmer, 1992 This may be explained by the results of Matuska and Erickson (2008) in
women with MS, showing that participants did not want to mix their identity with their
MS. They felt like they were more than just their disease and did not want to be defined
by it. The same study discovered that most of the participants were still interested in many
occupations but settled for an adaptation because they could not conduct the entire activity
as they did it in the past. One participant who was physically severely disabled and
therefore no longer able to garden herself, reported to engage in this meaningful activity
by accompanying her husband while he is working in the garden. Another study showed
that people who are not employed have lower perceived stress than the working ones
(Matuska, 2013). In the current study, 21 participants didn’t work, mostly because of their
impairments. A study by Matuska and Christiansen (2008) discovered that women with
MS make frequent changes to their life in order to achieve more life balance. These
findings maybe explain why the overall scores on the LBI were rather high.
46
The variation in age of the participants in this study was rather low: 77% of the
participants were between 51 and 65 years old, which makes the study methodological
less strong (Fawcett, 2007). We have tried to vary between ages as much as possible,
however the age category between 51 and 65 years old was highly representative of the
outpatient group of the rehabilitation centre in that period . One of the explanations might
be that the first symptoms of MS occur between the age of 20 and 40 years old, and in the
beginning the symptoms are mostly not very distinct or do not have a big influence on the
daily life of a patient (Healthline, 2015). The degenerating character of MS makes that
people lose their physical and cognitive functions gradually (Casetta & Graniere, 2009).
So in the beginning people don’t receive therapy one or more whole days a week but they
just receive therapy at home or because it is not that simple to come a whole day to the
centre in combination with a job. This study included 64% women and 36% men, which
is a representation of the MS population. The ratio of women with MS and men with MS
is 2:1 (Healthline, 2015).
The mean score of the relationship subscale was the lowest (mean = 2,3186). One
explanation might be that people who are ill try to find ways to bring more balance in
their lives by only putting energy into the relationships that are reciprocal or supportive
(Hakansson et al., 2010). Similarly, a study of Matuska & Erickson (2008) showed that
participants didn’t feel understood by their family and friends and they did not always
have energy left for their relationships and to keep up with everyone.
The challenge subscale had the second lowest mean score (mean = 2,3200). This may be
explained by the fact that people with MS don’t have much energy left after doing their
essential occupations so the challenging or rewarding activities are skipped (Matuska &
Erickson, 2008).
The health subscale had the highest mean score of all of the subscales (mean = 2,3805).
Research has shown that people with MS spend a large part of their day maintaining their
health, and to be able to do so they give up other activities (Matuska & Christiansen,
2008). So mostly people with MS are able to meet their needs on this subscale but have
too little time or energy left to do other activities, which can be one explanation why the
47
scores on the other subscales were lower. A more heterogenic group of MS-patients
compared to the healthy population could give some more information about this subject
and why the health subscale had such a high mean score.
5.2 Test-retest reliability
Fawcett (2007) state that the correlation between the first and second test moment should
be as high as possible for in order to have a good test-retest reliability. Terwee et al.
(2007) claim that the ICC should be at least 0,70 or higher to have a good test-retest
reliability. The correlation of the overall scores in this study was high (ICC = 0,904). This
suggests that the LBI has a very good test-retest reliability. This is in accordance with the
Life Balance Model, which states that life balance is sustainable and thus can be
maintained over the long term (Matuska & Christiansen, 2008). One of the possible
explanations if the instrument did not show good test-retest reliability could be that
balance is not as sustainable as the creators of the LBM and the LBI suggested. By
proving the test-retest reliability some validity evidence for the LBM is found as well.
The health subscale did have the lowest consistency between repeated measurements
(ICC = 0,641) but had still a good reliability. One explanation might be that managing
their health is a large part of their day for people with MS (Matuska & Erickson, 2008)
and small changes are detected more quickly than when a person does an activity only
once or twice a month (Matuska, 2012b).
5.3 Internal consistence
The internal consistency was good (α = 0,825), some items did contribute less (ex. items
9, 26, 30, 35, 45) and some contributed more (ex. items 10, 16, 17, 23, 27, 33, 34, 37, 40)
to the whole than others Yet deleting items is not favourable because life balance is
something personal and some activities are more general than others (Matuska, 2010).
And even if some items were deleted, it wouldn’t make that much difference (α = 0,813
48
– 0,838). Matuska (2012b) conducted two studies to test the psychometric properties of
the original LBI, she did also find a high Cronbach’s alpha (α = 0,89 – 0,97).
5.4 Construct validity
The construct validity of this instrument was measured by calculating correlations
between the LBI and other assessments that measure related concepts. Although there
should be a correlation, the correlation shouldn’t be too high because otherwise there
would be no difference between the LBI and the other test and they would measure the
same construct (Kielhofner, 2006; Matuska, 2010). The results showed significant
correlations between the LBI and the DASS-21 and the PWI-A ranging from -0,447 to -
0,827 and 0,430 to 0,694. This suggests that they are related but they don’t measure the
same construct. This can be confirmed by other research that suggest that there is a match
between the time people actually spend and the time they want to spend in activities and
health and well-being (Backman, 2004; Wilcock, Hall & Hambley, 1997). A more recent
study conducted by Matuska & Christiansen (2008) revealed that people with MS who
cannot engage in the activities they want to do or spend too much time on them,
experience a higher stress level.
The correlation between the LBI and the DASS-21 was the highest of them all (r = -
0,872). One possible explanation is that a balanced live is highly related to less stress,
more sleep and more physical activity. A study from Hakansson & Matuska (2011) with
women with a stress-related disorder showed that they became ill and imbalanced when
they felt an overload of stress and anxiety. A study of Matuska & Christiansen (2008)
showed that when people with MS had more stress, more symptoms of their disease would
occur. The people included in this current study had a well general health feeling resulting
in higher scores on the LBI and lower scores on the DASS-21.
The correlations between each subscale and the DASS-21 and the PWI-A are lower than
the correlations between the overall scores and the DASS-21 and the PWI-A. Some
subscales did have a higher impact on stress and others on well-being but they all
49
correlated in some way. This can be explained by the fact that all the subscales together
measure a construct that should relate to the constructs of other tests (Matuska 2010).
No significant relations were found between the LBI or any of the subscales and the
BPNS. This test was used because the LBM and LBI are created upon the self-
determination theory, which state that people need a balance of activities that meet
different needs (Deci & Ryan, 2000; Reis, Sheldon, Gable, Roscoe & Ryan, 2002). To
date, there is no assessment in Belgium that measures this construct. Because of this, there
has been decided to translate the BPNS into the Flemish language without validity or
reliability evidence. It can be argued that due to the poor methodological quality of this
test, no correlations have been found. These findings are in contrast to Matuska (2012)
her results, she did find a correlation between both tests.
5.5 Secondary analyses
The secondary analyses showed no differences between the overall scores within the
different demographical categories. These findings are not consistent with the findings of
Matuska (2012b), which suggested that the number of children, the employment status
and gender did have an influence on the scores of the LBI. It is uncertain why these results
have not been found in our study but one logical explanation might be that the sample
size was to small (n = 22) in comparison with Matuska’s (n = 458), a larger sample size
would have had more statistical power and differences would have been easier to detect
(Portney & Watkins, 2014).
Matuska (2013) found a difference in overall scores between the age group from 18 to 50
years and the group from 61 to 100 years. There was no significant difference between
the group from 51 to 60 years and both the other groups. Although no significant
differences were found within the age categories, the results of the study of Matuska were
in line with the current study. The oldest group in the study of Matuska was almost not
included in the current study, none of the participants were 65 years or older. And no
difference was found between 18 and 60 years in the study of Matuska which could
explain why no differences were found in the current study.
50
Another significant difference in the study of Matuska (2013) was found between people
who were unemployed and the ones that worked or were going to school. Except for one
participant, none of the participants in the current study had a job or went to school. This
might be the reason why no significant difference was found between the groups in the
current study, the power and sample size were too small to detect the differences. Matuska
(2012b) found the same results in a previous study: non-working people have a higher
life balance than the ones that are working or go to school.
5.6 Methodology
Several statistical calculations were conducted while trying to confirm the hypotheses.
All of these did contribute to the validity and reliability evidence, yet some other
calculations could have been done. Matuska (2010) conducted a rash analysis to see if all
the items on the test contributed to a common construct. The core concept is that the
comparison of two people has no link with which items might have been used within the
set of items that assess the same variable (Tennant, McKenna & Hagell, 2004).
Moreover, Matuska (2010) conducted a factor analysis to evaluate whether all items
fitted correctly in a model.. These methods have not been used in this study because of
limited sample size (Mundfrom, Dale & Lu Ke (2005) stat that at least 100 participants
are needed to conduct a factor analysis) and resources, and could be done in future
research. The general conclusions that Matuska (2010, 2012a, 2012b, 2013) concluded in
her studies can be concluded as well in this study.
The sample size of this study was limited, resulting in reduced power (Fawcett, 2007;
Kielhofner, 2008). Nevertheless, most of the results reached statistical significance.
One of the difficulties of this study was the lack of normative data for the general
population in Flanders. The LBI has been validated for the general population in the
United States but it is uncertain whether these results can be generalized to the Flemish
population (Fawcett, 2007). This difficulty could easily be solved by gathering data from
the healthy population and convert it into norms.
51
The LBM suggests that there is always an environmental influence on life balance
(Matuska, 2012a). The methodology used in the current study has not taken into account
this influence and thus it cannot be claimed that the environment indeed has an influence.
Although there can be assumed that the environment has an influence because (almost)
all of the occupational therapy models speak of an environmental influence (AOTA,
2002; Chapparo & Ranka, 1997; Christiansen & Baum, 2005; Law et al., 1996; Polatajko,
Townsend & Craik, 2007), further research regarding this subject should be conducted to
gain further validity evidence for the LBI.
53
6. Recommendations for further research
The evidence found in this study could be used in further research and is an addition to
the small amount of research regarding life balance. It is particularly relevant for the
occupational therapy practice in Flanders and potentially The Netherlands because there
were no instruments in Dutch/Flemish that measured life balance. By translating,
validating and testing this instrument, occupational therapists can keep up with the
phenomenon of life balance and eventually may make it one of the core concepts of the
daily practice in OT. On the basis of this test the therapist can determine in which parts
in his or hers life parts the client experience balance or imbalance. This will help the
therapist in making client-centred goals and it will help conducting interventions focused
on increasing the balance in one’s life or redistribute the balance (one might have a score
of 2,25 on the LBI but only score 1,5 on the challenge subscale and score 3,0 on the health
subscale). Helping clients finding balance in their lives may potentially lead to lower
stress levels and higher senses of well-being. By looking at a list of many activities clients
may think of doing things that they have never done before or that they had forgotten
about. In collaboration with the occupational therapist, clients can explore alternative
ways to perform the activity (either or not using adaptations of equipment), which will
likely lead to an increased level of balance and an increased activity capital.
Although this study indicated some good results it is highly recommended to do further
research. The topics in the following paragraphs could be interesting for further research.
Future research should include more people, resulting in increased power and the ability
of researchers to use item response based methods (ex. Rasch analysis) or factor analyses
to further explore the construct validity.
Only the construct validity was tested in this study. Fawcett (2007) claims that when an
instrument tries to describe and evaluate, the content and construct validity should be
tested. It could be interesting to examine the content validity in the future to gain more
supporting evidence for the LBI and the LBM. The equivalence part of the LBI was not
tested in this study. To validate the LBI and the LBM, it is important to check whether or
54
not equivalence is an important part. No conclusive evidence has been found in other
research regarding this subject (Matuska, 2012b).
Evidence has been found regarding the LBI and people with MS but to make the validity
evidence stronger, the general population should be tested. This makes it possible to
compare the results and provide normative data. The validity and reliability of the LBI
should be tested in other patient populations as well (e.g. psychiatric patients or patients
with other physical diseases). The LBI has only been used and tested in a few countries,
almost no evidence is available from outside the United States or Sweden. To make it
possible to compare with other countries, more research should be conducted in versions
of other languages.
This study also didn’t determine whether the LBI has a good responsiveness or not.
Terwee et al. (2007, p37) define responsiveness as: ‘The ability of a questionnaire to
detect clinically important changes over time, even if these changes are small.’ When
conducting further research about interventions with the LBI or when the instrument is
used in daily practice, it is important that the instrument is able to detect changes because
otherwise there is no use in using the LBI.
A practical guide for therapists could be useful. When they use the LBI with their patients
they will receive a score between zero and three but this does not say which activities are
more difficult than others and which subscale scores are better or worse than the others.
There is no concrete plan for therapists to use the LBI and this can be a threat for the
therapist to use the LBI. It could be useful to see if an additional interview, list, … would
be necessary for getting a full image of the patients balance.
55
7. Conclusion
The main focus of this study was to determine the reliability and construct validity of the
Flemish version of the Life Balance Inventory that measures the construct of ‘life
balance’. In this study participated 22 non-residential patients of the outpatient
department of the MS-centre at Melsbroek. They completed the LBI twice and the first
time they had to fill in three other tests as well that measured related constructs of life
balance.
The results of this study showed good test-retest reliability of the overall scores and all of
the subscales. No conclusive evidence was found regarding the construct validity: there
is a relation between life balance and stress and well-being, however the expected relation
between life balance and basic psychological needs is lacking. Secondary analyses
showed no differences of the overall LBI-scores within the different demographical
categories.
These findings provide support for the validity and reliability of the Flemish version of
the LBI. It can help the occupational therapy practice in Flanders (and the Netherlands)
by using the concept of life balance, which can eventually be one of the core concepts of
the daily practice.
57
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Appendixes
69
Appendix 1: Search strategy review of literature
The following databases have been consulted in order to find evidence to write the
introduction and method:
LIMO, PubMed, Google Scolar, Trip Database, OT-seeker and Medline.
The following searchterms (Mesh-terms and general terms) were used in different
combinations:
Occupational therapy, occupational science, founders, history, occupational therapy
models, Canadian Model of Occupation Performance and Engagement (CMOP-E),
Person-Environment-Occupation model (PEO), Person-Environment-Occupational-
Performance model (PEOP), Matuska, Christiansen, Life Balance, Work-life balance,
Life Balance Model, Life Balance Inventory, Multiple Sclerosis, MS, other disciplines,
wellbeing, well-being, health, occupational balance, balance, lifestyle balance,
occupational integrity, flow, engagement, occupations, activities, Meyer, Person,
Environment, Royeen, Pierce, Stamm, performance, ill-being, differences, gender, Dutch,
Flemish, American Association of Occupational Therapy, prevalence, age, validity,
construct validity, content validity, internal consistence, reliability, test-retest reliability,
sample size, statistics, quantitative research, time-pressure, Western culture,
occupational perspective, perceptions, work, leisure, self-maintenance, sleep,
relationships, goals, internal values, depression, mood, anxiety, basic psychological
needs, meaningful, imbalance, Westhorp, Kielhofner, psychology, psychological
attributes, psychological, healthful, activity patterns, interaction, identity, assessment,
other, health experience, engagement, engage, meaningful occupations, core business,
Self-determination Theory, Deci & Ryan, Maslow, Ryff & Singer, Ryff, stress, satisfying,
meaning, meaningful, satisfaction, context, activity configurations, individual, groups,
evidence, research, social, men, women, construct, ratio, DASS-21, Depression Anxiety
Stress Scales-21, Personal Wellbeing Index Adult, Basic Psychological Needs Scale,
BPNS, PWI-A, correlation, psychometric properties, results, profile, Occupational
Balance Questionnaire, OBQ, Meaningful Activity Wants and Needs Assessment,
MANWA, instrument, cause, treatment, origin, quality of life, symptoms, cognitive
impairments, fatigue, secondary symptoms, activities of daily living, translating,
70
translating process, Nationaal MS-centrum Melsbroek, statistical calculation, design,
research design, power, RAO, BRB-N, Rao’s Brief Repeatable Battery of
Neuropsychological Tests, prognosis, ICF, bias, recall-bias, influence, demographic
questionnaire, demographic, EQ-5D, Nederlands, ethics, ethical considerations.
Further search has been conducted on the basis of the references of the different articles,
books, … Beside this, some of the basics of occupational therapy and occupational
science were used.
71
Appendix 2: Information letter
Informatiebrief voor deelname aan een wetenschappelijk onderzoek
Geachte mevrouw, mijnheer,
Via deze brief verzoeken wij u om medewerking aan een wetenschappelijk onderzoek. Dit
onderzoek wordt uitgevoerd in functie van een masterproef die kadert binnen de opleiding
Master in de Ergotherapeutische Wetenschap van de KU Leuven.
Onderstaande informatie kan u meer uitleg bieden en helpen te beslissen of u al dan niet aan
deze studie wenst deel te nemen. Indien u vragen of opmerkingen heeft, kan u zich steeds
richten tot de personen die onderaan deze brief vermeld staan. Wij raden u aan deze brief te
bewaren zodat u deze in de toekomst nog kan raadplegen.
Titel van het wetenschappelijk onderzoek:
Validatie- en betrouwbaarheidsstudie van de Life Balance Inventory
1. Doel
Met het huidige onderzoek willen we nagaan of de Life Balance Inventory een bruikbare test is
om life balance in kaart te brengen bij personen met MS. Life balance is het gevoel van balans
dat u als persoon ervaart. U voert dagelijks activiteiten uit, de ene activiteit vindt u al wat leuker
dan de andere. Voor uw welzijn is het belangrijk dat u tevreden bent met de activiteiten die u
uitvoert en dat deze activiteiten voor u gezond, betekenisvol en van lange duur zijn.
Het doel van de Life Balance Inventory is om alle activiteiten in kaart te brengen die u doet,
graag zou doen en graag minder zou willen doen. Aan de hand van de resultaten kan er dan
72
gerichtere therapie aangeboden worden die uw welzijn kan verhogen door te focussen op de
activiteiten die u zelf belangrijk vindt.
2. Metingen en procedures
De gegevens zullen verzameld worden aan de hand van enkele vragenlijsten die u dient in te
vullen in het Nationaal Multiple Sclerose Center te Melsbroek. Het invullen van de testen zal
maximaal 1 uur duren, u kunt zelf kiezen of u alle vragenlijsten vlak na elkaar invult of dat u
enkele pauzes neemt.
Om te kijken of de test ook nog hetzelfde resultaat geeft na 1-2 weken vragen wij u om één van
de vragenlijsten, de Life Balance Inventory, opnieuw in te vullen na deze periode. Dit zal
ongeveer nog een half uur van uw tijd in beslag nemen.
De Lokale Ethische Commissie van het Nationaal Multiple Sclerose Centrum te Melsbroek, heeft
de studie goedgekeurd.
3. Wat mag u van ons verwachten
De vragenlijsten die u invult, zullen discreet verwerkt worden en zullen niet aan derden
worden doorgegeven, tenzij u dat wenst;
De onderzoeksresultaten zullen geen identificatiegegevens bevatten en dus anoniem
behandeld worden;
De resultaten van dit onderzoek zullen worden gepubliceerd in de masterproef en een
wetenschappelijke tijdschrift, de rapportering gebeurt steeds anoniem;
De verkregen informatie wordt enkel gebruikt in functie van het onderzoek. U kunt wel
uw resultaten verkrijgen voor persoonlijk gebruik en/of te delen met uw arts/therapeut.
4. Wat zijn uw rechten
U mag steeds vragen stellen in verband met het onderzoek aan de onderzoeker;
U neemt deel uit vrije wil;
U kan op elk moment in het onderzoek beslissen om uw deelname aan deze studie stop
te zetten, door dit aan de onderzoeker te melden. Deze stopzetting zal geen enkele
invloed hebben uw verdere behandeling binnen het centrum.
73
5. Risico’s
Er zijn geen risico’s verbonden aan dit onderzoek.
6. Vergoeding
Er is geen vergoeding voorzien voor deelname.
Indien gewenst kunnen de resultaten van de testen doorgegeven worden aan u en/of
de behandelende therapeuten in het centrum.
Contactgegevens onderzoekers:
Daphne Kos – 0496/10.78.49 – [email protected] of [email protected]
Sven Van Geel – 03/641.82.41 – [email protected]
Hélène Dirix – 0475/32.58.42 – [email protected]
Karen Verbeek – 02/597.86.93 (Dienst ergotherapie MS Centrum Melsbroek)
75
Appendix 3: Informed consent
INSTRUCTIES VOOR DE DEELNEMER: gelieve deze vragenlijst zelf in te vullen
1. Hebt u de informatiebrief gelezen? JA NEE
2. Hebt u de mogelijkheid gehad om vragen te stellen over de studie? JA NEE
3. Hebt u voldoende antwoorden gekregen op uw vragen? JA NEE
4. Hebt u genoeg informatie ontvangen over de studie? JA NEE
5. Begrijpt u dat u vrij bent om de studie stop te zetten: JA NEE
a. Op elk moment
b. Zonder verantwoording te moeten geven voor de stopzetting
c. Zonder dat dit uw verdere medische opvolging zal beïnvloeden
6. Gaat u akkoord om deel te nemen aan deze studie? JA NEE
7. Gaat u akkoord om gegevens verzameld tijdens deze studie op te nemen
in een gegevensbestand? JA NEE
De Lokale Ethisch Commissie van het Nationaal MS Centrum heeft de studie als ethisch
verantwoord goedgekeurd.
Ik heb deze tekst grondig gelezen, begrijp het verloop van het onderzoek en verbind me ertoe,
om op vrijwillige basis, aan het onderzoek deel te nemen.
Naam:………………………………………………………… Naam:…………………………………………………………
Voornaam:………………………………………………… Voornaam:…………………………………………………
Datum:................../….............../.................. Datum:................../….............../..................
Plaats:………………………………………………………. Plaats:……………………………………………………….
HANDTEKENING DEELNEMER: HANDTEKENING ONDERZOEKER:
Validatie- en betrouwbaarheidsstudie van de Life Balance
Inventory
77
Appendix 4: Life Balance Inventory (Flemish version)
INSTRUCTIES:
STAP 1: Geef aan of u de activiteit uitvoert of ze wil uitvoeren door JA of
NEE aan te duiden.
STAP 2: Voor de activiteiten waar u JA heeft aangeduid, dient u na te denken
hoeveel tijd u hier de afgelopen maand heeft ingestoken. Duid/scoor de
vergelijking aan tussen de tijd die u daadwerkelijk heeft gespendeerd en de
tijd die u er aan zou willen spenderen.
STAP 2: Voor de activiteiten waar u JA
heeft aangeduid. De hoeveelheid tijd die ik
spendeer aan deze activiteit is …
STAP 1: ALTIJD SOMS ONGEVEER SOMS ALTIJD
IK DOE deze activiteit MINDER MINDER JUIST MEER MEER
IK WIL deze activiteit doen dan ik wil/dan ik wil/voor mij/dan ik wil/dan ik wil
Ja Nee Zorg dragen voor persoonlijke
hygiëne en uzelf wassen
1 2 3 2 1
Ja Nee Zorg dragen voor uw uiterlijk 1 2 3 2 1
Ja Nee Zorg dragen voor voldoende slaap 1 2 3 2 1
Ja Nee Ontspannen/rusten 1 2 3 2 1
Ja Nee Zorgen voor regelmatige beweging 1 2 3 2 1
Ja Nee Voedzaam eten 1 2 3 2 1
Ja Nee Zorgen voor eigen
gezondheidsbehoeften
1 2 3 2 1
Ja Nee Geld beheren
(rekeningen/budget/investeringen)
1 2 3 2 1
Ja Nee Rijden 1 2 3 2 1
Ja Nee Gebruik maken van openbaar
vervoer
1 2 3 2 1
Ja Nee Tijd spenderen met familieleden 1 2 3 2 1
Ja Nee Tijd spenderen met partner 1 2 3 2 1
Ja Nee Tijd spenderen met vrienden 1 2 3 2 1
Ja Nee Zorg dragen voor kinderen of
familieleden
1 2 3 2 1
Ja Nee Sexueel actief zijn 1 2 3 2 1
Ja Nee Deelnemen aan groepen
(verenigingen, cursussen etc.)
1 2 3 2 1
Ja Nee Nieuwe mensen ontmoeten 1 2 3 2 1
78
STAP 2: Voor de activiteiten waar u JA
heeft aangeduid. De hoeveelheid tijd die ik
spendeer aan deze activiteit is …
STAP 1: ALTIJD SOMS ONGEVEER SOMS ALTIJD
IK DOE deze activiteit MINDER MINDER JUIST MEER MEER
IK WIL deze activiteit doen dan ik wil/dan ik wil/voor mij/dan ik wil/dan ik wil
Ja Nee Betaalde arbeid verrichten 1 2 3 2 1
Ja Nee Uzelf ontwikkelen in uw job 1 2 3 2 1
Ja Nee Sociale contacten hebben op
het werk
1 2 3 2 1
Ja Nee Deelnemen aan formele
religieuze activiteiten
1 2 3 2 1
Ja Nee Deelnemen aan festiviteiten,
feestdagen vieren
1 2 3 2 1
Ja Nee Deelnemen aan
mogelijkheden tot bijscholing
1 2 3 2 1
Ja Nee Deelnemen aan professionele
organisaties
1 2 3 2 1
Ja Nee Vrijwilligerswerk uitvoeren in
de gemeenschap
1 2 3 2 1
Ja Nee Deelnemen aan
georganiseerde sport
1 2 3 2 1
Ja Nee Buitenactiviteiten doen 1 2 3 2 1
Ja Nee Tuinieren 1 2 3 2 1
Ja Nee Genieten van de natuur 1 2 3 2 1
Ja Nee Plannen en organiseren van
evenementen
1 2 3 2 1
Ja Nee Decoreren en inrichten van
ruimtes
1 2 3 2 1
Ja Nee Koken 1 2 3 2 1
Ja Nee Huishoudelijk werk uitvoeren 1 2 3 2 1
Ja Nee Gaan winkelen 1 2 3 2 1
Ja Nee Huisdieren verzorgen 1 2 3 2 1
Ja Nee Naar restaurant/café gaan 1 2 3 2 1
Ja Nee Naar film, theater, sportieve
evenementen gaan
1 2 3 2 1
79
STAP 2: Voor de activiteiten waar u JA
heeft aangeduid. De hoeveelheid tijd die ik
spendeer aan deze activiteit is …
STAP 1: ALTIJD SOMS ONGEVEER SOMS ALTIJD
IK DOE deze activiteit MINDER MINDER JUIST MEER MEER
IK WIL deze activiteit doen dan ik wil/dan ik wil/voor mij/dan ik wil/dan ik wil
Ja Nee Hobby's uitvoeren 1 2 3 2 1
Ja Nee Muziek maken 1 2 3 2 1
Ja Nee Artistiek bezig zijn 1 2 3 2 1
Ja Nee Onderhouden of repareren van
materiaal
1 2 3 2 1
Ja Nee Naaien/naaldwerk 1 2 3 2 1
Ja Nee Lezen 1 2 3 2 1
Ja Nee Gebruik maken van computer,
laptop, tablet, smartphone
1 2 3 2 1
Ja Nee Reflecteren of mediteren 1 2 3 2 1
Ja Nee Dagboek bijhouden 1 2 3 2 1
Ja Nee Componeren, schrijven
(muziek, gedichten etc.)
1 2 3 2 1
Ja Nee Dansen, yoga etc. 1 2 3 2 1
Ja Nee Vaardigheidsspellen spelen 1 2 3 2 1
Ja Nee TV kijken 1 2 3 2 1
Ja Nee Begeleiden van anderen
(mentor)
1 2 3 2 1
Ja Nee Reizen (alle vorm van reizen) 1 2 3 2 1
Ja Nee Verhalen vertellen 1 2 3 2 1
81
Appendix 5: Demographical questionnaire
Beantwoord volgende vragen kort of kleur bij volgende vragen het bolletje
voor het antwoord, dat voor u van toepassing is, in:
1. Geboortedatum: …………………….
2. Geslacht:
o Man
o Vrouw
3. Burgerlijke stand:
o Alleenstaand
o Gehuwd
o Samenwonend
o Gescheiden
o Weduwe/weduwnaar
4. Aantal kinderen: …………………….
5. Aantal kinderen nog ten laste: …………………….
6. Hoelang heeft u al multiple sclerose:
o < 5 jaar
o 5 – 10 jaar
o 10 – 15 jaar
o 15 – 20 jaar
o > 20 jaar
7. Werksituatie:
o Werkend
o (tijdelijk) werkloos
o Werkzoekend
o Invalide
o Pensioen
o Student
o Ander: …………………….
82
8. Hoogst behaalde diploma:
o Lager onderwijs
o Lager middelbaar onderwijs
o Hoger middelbaar onderwijs
o Bachelor/graduaat
o Master/licentiaat
o Doctoraat
o Ander: …………………….
Kleur bij volgende vragen het bolletje voor de zin die het beste uw
gezondheidstoestand van vandaag weergeeft:
9. Mobiliteit:
o Ik heb geen problemen met me te verplaatsen
o Ik heb enige problemen met me te verplaatsen
o Ik heb zeer ernstige problemen met me te verplaatsen
10. Zelfzorg:
o Ik heb geen problemen om voor mezelf te zorgen
o Ik heb enige problemen om mezelf te wassen of aan te kleden
o Ik ben niet in staat mezelf te wassen of aan te kleden
11. Dagelijkse activiteiten (Bijvoorbeeld: werk, studie, huishouden, gezins- of
vrijetijdsactiviteiten):
o Ik heb geen problemen met mijn dagdagelijkse activiteiten
o Ik heb enige problemen met mijn dagdagelijkse activiteiten
o Ik ben niet in staat om mijn dagdagelijkse activiteiten uit te voeren
12. Pijn/klachten:
o Ik heb geen pijn of andere klachten
o Ik heb matige pijn of andere klachten
o Ik heb zeer ernstige pijn of andere klachten
13. Angst/depressie:
o Ik ben niet angstig of depressief
o Ik ben matig angstig of depressief
o Ik ben erg angstig of depressief
83
Appendix 6: DASS-21 (Flemish version)
INSTRUCTIES:
Geef voor ieder van onderstaande uitspraken aan in hoeverre de uitspraak
afgelopen week voor u van toepassing was door een antwoord aan te
kruisen. Er zijn geen goede of foute antwoorden. Besteed niet te veel tijd aan
iedere uitspraak, het gaat om uw eerste indruk.
VRAGEN:
1. Ik vond het moeilijk om mezelf te kalmeren:
o Helemaal niet of nooit van toepassing
o Een beetje of soms van toepassing
o Behoorlijk of vaak van toepassing
o Zeer zeker of meestal van toepassing
2. Ik had de neiging om overdreven te reageren op situaties:
o Helemaal niet of nooit van toepassing
o Een beetje of soms van toepassing
o Behoorlijk of vaak van toepassing
o Zeer zeker of meestal van toepassing
3. Ik was erg opgefokt
o Helemaal niet of nooit van toepassing
o Een beetje of soms van toepassing
o Behoorlijk of vaak van toepassing
o Zeer zeker of meestal van toepassing
4. Ik merkte dat ik erg onrustig was
o Helemaal niet of nooit van toepassing
o Een beetje of soms van toepassing
o Behoorlijk of vaak van toepassing
o Zeer zeker of meestal van toepassing
84
5. Ik vond het moeilijk om me te ontspannen
o Helemaal niet of nooit van toepassing
o Een beetje of soms van toepassing
o Behoorlijk of vaak van toepassing
o Zeer zeker of meestal van toepassing
6. Ik had volstrekt geen geduld met dingen die me hinderden bij iets dat ik wilde
doen
o Helemaal niet of nooit van toepassing
o Een beetje of soms van toepassing
o Behoorlijk of vaak van toepassing
o Zeer zeker of meestal van toepassing
7. Ik merkte dat ik nogal licht geraakt was
o Helemaal niet of nooit van toepassing
o Een beetje of soms van toepassing
o Behoorlijk of vaak van toepassing
o Zeer zeker of meestal van toepassing
85
Appendix 7: PWI-A (Flemish version)
INSTRUCTIES:
De volgende stellingen peilen naar hoe tevreden u zich voelt op een schaal
van 0 tot 10. 0 betekent dat u zich helemaal ontevreden voelt, 10 betekent
dat u zich helemaal tevreden voelt. Het midden van de schaal is 5, dit
betekent dat u zich neutraal voelt, niet tevreden maar ook niet ontevreden.
Helemaal Helemaal
ontevreden Neutraal tevreden
0 1 2 3 4 5 6 7 8 9 10
1 Hoe tevreden bent u met uw leven
in het algemeen?
0 1 2 3 4 5 6 7 8 9 10
2 Hoe tevreden bent u met uw
levensstandaard?
0 1 2 3 4 5 6 7 8 9 10
3 Hoe tevreden bent u met uw
gezondheid?
0 1 2 3 4 5 6 7 8 9 10
4 Hoe tevreden bent u met wat u op
dit moment bereikt hebt in uw
leven?
0 1 2 3 4 5 6 7 8 9 10
5 Hoe tevreden bent u met uw
persoonlijke relaties?
0 1 2 3 4 5 6 7 8 9 10
6 Hoe tevreden bent u met uw
veiligheidsgevoel?
0 1 2 3 4 5 6 7 8 9 10
7 Hoe tevreden bent u met de mate
waarin u zich onderdeel van uw
gemeenschap voelt?
0 1 2 3 4 5 6 7 8 9 10
8 Hoe tevreden bent u met uw
zekerheid voor de toekomst?
0 1 2 3 4 5 6 7 8 9 10
9 Hoe tevreden bent u met uw
godsdienst of levensovertuiging?
0 1 2 3 4 5 6 7 8 9 10
87
Appendix 8: BPNS (Flemish version)
INSTRUCTIES:
Lees de volgende items erg aandachtig, denk na over hoe dit in uw leven is,
en omcirkel dan hoe waar dit is voor u. Gebruik volgende schaal:
Helemaal Beetje Helemaal
niet waar waar waar
1 2 3 4 5 6 7
1 Ik heb het gevoel dat ik vrij ben om zelf te
beslissen hoe ik mijn leven leid.
1 2 3 4 5 6 7
2 Ik heb de mensen waarmee ik in interactie ga
echt graag.
1 2 3 4 5 6 7
3 Soms voel ik me niet echt
competent/bekwaam.
1 2 3 4 5 6 7
4 Ik voel me onder druk gezet in mijn leven. 1 2 3 4 5 6 7
5 Mensen die ik ken, vertellen me dat ik goed ben
in wat ik doe.
1 2 3 4 5 6 7
6 Ik kom overeen met mensen met wie ik in
contact kom.
1 2 3 4 5 6 7
7 Ik ben vooral op mezelf en heb niet veel sociaal
contact.
1 2 3 4 5 6 7
8 In het algemeen voel ik me vrij om mijn ideeën
en opinies te verkondigen.
1 2 3 4 5 6 7
9 Ik beschouw de mensen waarmee ik regelmatig
contact heb als mijn vrienden.
1 2 3 4 5 6 7
10 Ik ben recent in staat geweest om interessante
nieuwe vaardigheden te leren.
1 2 3 4 5 6 7
11 In mijn dagelijks leven moet ik vaak doen wat
men mij zegt te doen.
1 2 3 4 5 6 7
12 De mensen in mijn leven geven om mij. 1 2 3 4 5 6 7
13 De meeste dagen haal ik een gevoel van
vervulling uit wat ik doe.
1 2 3 4 5 6 7
14 De mensen met wie ik dagelijks contact heb
nemen vaak mijn gevoelens in overweging.
1 2 3 4 5 6 7
15 Ik krijg niet veel kansen in mijn leven om te
tonen hoe capabel ik ben.
1 2 3 4 5 6 7
16 Er zijn niet veel mensen waar ik close mee ben. 1 2 3 4 5 6 7
17 Ik heb het gevoel dat ik ongeveer mezelf kan
zijn in dagelijkse situaties.
1 2 3 4 5 6 7
18 De mensen met wie ik veel contact heb lijken
me niet al te graag te hebben.
1 2 3 4 5 6 7
19 Ik voel me soms niet erg capabel. 1 2 3 4 5 6 7
88
20 Er zijn niet veel mogelijkheden voor mij om
voor mezelf te beslissen hoe ik de dingen wil
doen in mijn dagelijks leven.
1 2 3 4 5 6 7
21 Mensen zijn in het algemeen vrij vriendelijk
tegen mij.
1 2 3 4 5 6 7