Definitions of occupational balance and their coverage by instruments

1. Critical Review
Definitions of occupational balance and their
coverage by instruments
Mona Du¨r1
, Julia Unger2
, Michaela Stoffer3
, Ra˘zvan Dra˘goi4
,
Alexandra Kautzky-Willer5
, Veronika Fialka-Moser6
, Josef Smolen7
and
Tanja Stamm8
Abstract
Introduction: Occupational balance is an important and widely used concept in occupational therapy and occupational science.
There is, however, not one unified definition in use, but several different ones, and thus instruments that measure the concept in
research studies are diverse as well. Consequently, it is unclear how instruments and definitions correspond. The purpose of this
study was to examine the coverage of occupational balance definitions by occupational balance instruments.
Method: Within a mixed-methods design we conducted a qualitative and quantitative content analysis of definitions and items of
existing instruments. Definitions and items were extracted from articles identified in a systematic literature search. The extent of
congruence and coverage between definitions and instruments was examined.
Results: The definitions used in 47 articles were structured into 19 categories. The categories which were found in most definitions
were a balance of ‘various occupational patterns and areas’ (42; 89%) and ‘occupational accomplishment, performance, roles and
responsibilities’ (35; 75%); 20 instruments were explored. Together they covered 16 (84%) of the 19 categories.
Conclusion: Knowing which instruments cover which dimensions of occupational balance can support occupational therapists,
other health professionals and health researchers in their selection of an instrument to measure occupational balance.
Keywords
Occupational science, assessments, content analysis, outcome research, conceptualisation
Received: 4 February 2014; accepted: 7 July 2014
Introduction
Occupational balance is an important concept in occupa-
tional therapy and occupational science. Occupational
balance has been considered as crucial for health and well-
being since the very beginning of occupational therapy
(Meyer, 1977; Rogers, 1984). Occupational therapists cur-
rently explore various concepts to get a comprehensive
picture of occupation, such as occupational balance
(Creek, 2010; Gutman and Schindler, 2007). In order to
identify patients’ needs for interventions that target occu-
pational balance (AOTA, 2011), and to evaluate their
effects, occupational therapists need to know underlying
dimensions and how to measure them.
There is no single definition of occupational balance
(Anaby et al., 2010b). Most recently, occupational balance
was defined as subjective ‘perception of having the right
amount and variation of occupations’ (Wagman et al.,
2012a). Furthermore, occupational balance is occasionally
used in relation to or synonymously with life balance, life-
style balance or work–life balance (Matuska, 2012b;
Wagman et al., 2012b). Occupational therapists need a
tangible definition of occupational balance, which should
reflect the concept as accurately as possible to contribute
to the comparability of studies on occupational balance.
Definitions of occupational balance have been explored in
existing literature. Two of these articles address the urgent
task not only to provide a concise definition of occupational
1
Lecturer and Researcher, Department of Health Sciences, IMC University of
Applied Sciences Krems, Austria; Lecturer, Researcher and PhD Candidate,
Medical University of Vienna, Vienna, Austria
2
Lecturer and Researcher, FH Joanneum, Bad Gleichenberg, Austria
3
Research Fellow and PhD Candidate, Department of Internal Medicine,
Medical University of Vienna, Vienna, Austria
4
Assistant Professor, Department of Rehabilitation, Physical Medicine and
Rheumatology, Victor Babes University of Medicine and Pharmacy,
Romania
5
Head of Gender Medicine Unit, Deputy Head of Internal Medicine III,
Medical University of Vienna, Vienna, Austria
6
Head of Department of Physical Medicine and Rehabilitation, Medical
University of Vienna, Vienna, Austria
7
Head of Department of Internal Medicine III, Medical University of Vienna,
Vienna, Austria
8
University of Applied Health Sciences, Austria
Corresponding author:
Tanja Stamm, Head of Research Group for Clinimetrics, Department of
Internal Medicine III, Division of Rheumatology, Medical University of
Vienna, Spitalgasse 23, A-1090 Vienna, Austria, and Head of Master
Degree Program ‘‘Health Assisting Engineering’’, FH Campus Vienna,
Favoritenstraße 226, 1100 Vienna, Austria.
Email: tanja.stamm@meduniwien.ac.at
The British Journal of Occupational
Therapy
2015, Vol. 78(1) 4–15
! The Author(s) 2014
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DOI: 10.1177/0308022614561235
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2. balance, based on current literature, but also to explore the
history and variety of definitions for occupational balance
(Backman, 2004; Wagman et al., 2012a). For example,
Wagman et al. (2012a) used a concept analysis to clarify the
content of occupational balance definitions and finally gave a
concise definition. Furthermore, three perspectives were
found to be used in relation to occupational balance
(Wagman et al., 2012a). The results did not assign certain
articles to the identified concepts referring to occupational
balance. Furthermore, the frequency of their occurrence was
not reported. Additionally, the conceptualisation of balance
was explored previously (Reece et al., 2009; Wada et al., 2010;
Westhorp, 2003). Wada et al. (2010) examined different con-
cepts and perspectives of balance, including occupational and
life balance (Wada et al., 2010). However, the conceptualisa-
tion of occupational and life balance was not described and
discussed extensively. Thus, these articles did not report data
that could be further used to explore the coverage of the def-
initions of occupational and/or life balance by existing instru-
ments. Moreover, both articles did not provide a detailed
presentation of the different contents of the definitions with
a systematic illustration of the methods used and the results
extracted. From this point on the term ‘instruments’ encom-
passes measurements, questionnaires and single items.
Numerous instruments are currently available that can be
used to assess occupational balance. Based on the different
existing definitions, instruments that measure the concept in
research studies are diverse as well. Consequently, it is
unclear how instruments and definitions correspond. If occu-
pational therapists want to select an instrument to evaluate
their interventions, they need to know which dimensions are
or are not covered by an instrument and about their psy-
chometric properties (Mokkink et al., 2010a, 2010b). The
psychometric properties of several instruments to measure
occupational balance have been discussed and critically
appraised elsewhere (Anaby et al., 2010b; Backman, 2001;
Bejerholm and Eklund, 2006a; Christiansen, 1996;
Ha˚ kansson et al., 2009). However, there is no content com-
parison of the existing instruments and the dimensions of
occupational balance covered by these instruments. Such an
overview would help clinicians and researchers to easily
select the appropriate instrument. Thus, we find it is impera-
tive to first compare definitions currently used. In order to
add value to the currently existing gap of information about
occupational balance definitions and instruments, a system-
atic literature search and content analysis is needed.
The purpose of this study was to examine the coverage
of occupational balance definitions by occupational bal-
ance instruments. Therefore, we aimed to (a) identify exist-
ing occupational balance definitions and instruments that
were developed and/or used to measure occupational bal-
ance, (b) examine their contents and (c) explore which
instruments cover those definitions.
Methods
Within a mixed-methods design we conducted a qualita-
tive and quantitative content analysis (Creswell, 2003) sep-
arately, of definitions and items of existing instruments.
Definitions and items were extracted from articles identi-
fied in a systematic literature search. The extent of con-
gruence and coverage between definitions and instruments
was examined.
Systematic literature search
In the first step, a systematic literature search was con-
ducted to identify articles on and definitions of ‘occupa-
tional balance’ and ‘life balance’, as well as instruments
that were developed or used to measure these concepts.
The search was done in 2013 using PubMed, CINAHL
and Web of Science.
To be eligible for review, an article needed to meet the
following inclusion criteria: titles and abstracts containing
the keywords ‘occupational balance’ or ‘life balance’; an
explicit definition of occupational and/or life balance or
description of an instrument used to measure occupational
and/or life balance; published in English in a peer-reviewed
scientific journal; and had at least one author who was an
occupational therapist. The latter criterion was established
to find articles relevant to occupational therapy, and to
avoid the identification of articles that refer to occupation
as paid work exclusively. Additionally, articles referring to
‘postural’ or ‘physical’ balance, or related ‘balance dis-
orders’ were excluded due to irrelevance. Life balance was
used as a keyword because some authors refer to this term
as occupational balance synonymously (Matuska, 2012b;
Wagman et al., 2012b). However, in order to provide infor-
mation about which articles were identified by the search on
which term (occupational or life balance) and which cate-
gories have been used in relation to which concept, the
results were presented separately. Articles referring to ‘bal-
ance of occupations’, ‘work–life balance’, ‘lifestyle balance’
and a ‘balanced life’ were included. Year of publication was
not a criterion for inclusion of an article.
Once candidate articles were identified, they were inde-
pendently reviewed by three researchers (MD, JU and
Alexa Binder [AB]) through the use of a data extraction
form to extract occupational and/or life balance definitions
and occupational or life balance instruments. The team
members verified the accuracy of data extraction by con-
currence. The selected articles were read mindfully by the
three researchers. All sections (abstract, introduction, meth-
ods, results, discussion and conclusions) were screened for
text sequences referring to ‘occupational’ and/or ‘life bal-
ance’. Those definitions that were identified by the three
researchers were selected. In case of disagreement, discussion
led to a shared decision and the selection or exclusion of a
text sequence. Subsequently, the content of these text
sequences on occupational and/or life balance was listed
and used for further analysis. Similarly, a data extraction
form was used to identify instruments measuring one or
more aspects of occupational and/or life balance. To be eli-
gible, an instrument needed to have a stated purpose to be
developed or used as measurement of occupational and/or
life balance, identified by two researchers (MD and JU). In
case of disagreement, a third researcher (AB) made a deci-
sion regarding the selection or exclusion of an instrument.
Du¨r et al. 5

3. Since it was not the aim of this project, we did not consider
other psychometric properties of the instruments. If the
items of an instrument were not specified in the article they
were extracted from the original source.
Qualitative content analysis
Both occupational and life balance definitions, as well as
instruments’ items, were then listed and thematically clus-
tered by the use of meaning categorisation, a qualitative
content analysis, as described by Kvale (1996). First, these
lists were reduced by the creation of sub-categories, thus
condensing the meaning of the original definitions or instru-
ment items. Second, overlapping categories were combined
(details are explained in the example at the results section).
The meaning of the selected definitions and items was
explored and categorised by two authors independently (def-
initions: AB and MD; instruments: MD and JU). The iden-
tified categories did not have to be mutually exclusive, based
on their occurrence in the text sequences referring to occu-
pational and/or life balance. Items that did not result in the
same interpretation by both analysts were discussed. In add-
ition to this exchange, a third occupational therapist, not
involved in the previous analysis (Stefanie Haider), was
asked to mediate this process and come to a decision. This
process was completed and documented in Excel files. The
identified categories within the selected articles, as well as the
categories identified in the instruments, were summarised.
One item could encompass more than one category. Below
we provide an example of the analysis in which sub-cate-
gories and categories were created based on a specific
quote. In Eklund et al. (2009b), occupational balance is
defined as ‘a balance between work, rest and play measured
in time’. Based on this quote, the following two sub-cate-
gories were created: a ‘balance of work, rest and play’ and a
‘balance of time used for work, rest and play’. Out of the
final categories (after combining overlapping sub-categories)
the following two were reassigned to this quote: a balance of
‘various occupational patterns and areas’ and of ‘time spent,
time use, time pressure, pace and/or rhythm’.
Quantitative content analysis
Furthermore, we conducted a quantitative content analysis
and used descriptive statistics to explore the frequency of
the identified categories and the extent of their coverage by
the instruments. The number of articles per identified cat-
egory was calculated. Categories mentioned only in a max-
imum of three articles (1.3%) were not considered for
further investigation. Additionally, categories identified in
more than two-thirds (>66%) of the articles were defined as
the ‘core’ dimensions of occupational and life balance.
In the final step, the researchers matched instruments to
definitions in order to report how many instruments were
available to assess each category of occupational and life
balance definitions and to note definitions for which no
instrument existed. This study was part of a larger study,
namely the gender, occupational balance and immunology
(GOBI) study (Du¨ r et al., 2014a).
Results
Selected articles
The literature search resulted in a total of 517 results, 16
on occupational balance in PubMed, 43 in CINAHL and
18 in Web of Science. The literature search on life balance
brought 263 results in PubMed, 43 in CINAHL and 134 in
Web of Science. Of these, 26 articles were duplicates and
were therefore removed; another 444 articles were
excluded due to their irrelevant contents. Finally, 47 art-
icles were used for further analysis: 26 articles on occupa-
tional balance, 15 articles on life balance and six which
contained both occupational and life balance in the titles
and/or abstracts. Consequently, a total of 32 articles on OB
and a total of 21 articles on LB, of which six were the same,
were used for further analyses. Of the 47 articles, 13 pro-
vided information on the instrument items, while six add-
itional articles were used to obtain instrument items. Thus,
a total of 19 articles were used for the extraction of instru-
ment items. The articles’ selection process by the literature
search is shown in Appendix 1 (Moher et al., 2009).
In the tables, we referred to the specific articles and instru-
ments thematically in an alphabetical order of the first
authors’ names using the reference number of the articles,
as listed in Appendix 2.
We found 21 articles that described the use or develop-
ment of 17 different occupational balance and two life
balance instruments, and one instrument (Q sort pack)
(Wagman et al., 2012b) that measured both occupational
and life balance. Half of the articles reported the use of
one instrument, eight articles described the use of two to
three instruments and one article referred to the use of
four different occupational balance instruments. The last
row of Table 1 represents the number of identified occu-
pational and life balance instruments per article. In total,
20 instruments were described.
Identified categories
Definitions. We identified 96 sub-categories in the extracted
occupational and life balance definitions, which were finally
combined into a total of 19 categories (see Table 1, first
column (columns ¼ articles; rows ¼ categories)). An exam-
ple is the category ‘equilibrium and congruence among
occupations’. It contained the following sub-categories: sat-
isfaction and dissatisfaction of occupations; congruence
between desired, ideal and actual occupational patterns; con-
gruence and equivalence in activity configuration; equiva-
lence in the degree of discrepancy between desired and
actual time spent across activities that meet different needs.
The following categories were identified as ‘core’
dimensions: a balance of ‘various occupational patterns
and areas’ (42; 89%); ‘occupational accomplishment, per-
formance, roles and responsibilities’ (35; 75%); ‘determin-
ant of health’ (34; 72%); a balance of ‘time spent, time use,
time pressure, pace and/or rhythm’ and ‘capabilities and
challenges’ (both 33; 70%). The percentage of the numbers
of articles per category is presented in Appendix 3.
6 The British Journal of Occupational Therapy 78(1)

4. Table1.Identifiedcategoriesperarticle.
Categories
Referencesofarticlesonoccupationalbalance
12345678910111213141516
Biologicalneed«
Determinantofhealth«««««««««
Determinantof,oressentialfor,lifesatisfaction
Dynamicstateandon-goingprocess««««««««
Engagementinmeaningfuloccupations««««
Equilibriumandcongruenceamongoccupations«Â««««««
Subjectiveandindividual«Â««
*abilitiesandrestrictionstoadaptoccupations«««««
*social,physicalandmentalwellbeing«
*capabilitiesandchallenges«««««««««Â
*caringforoneselfandothers«««
*chosenandobligatoryoccupations«««
*harmonyandconflictamongoccupations««««
*occupations(more/less)meaningfulfortheindividual
andsocio-culturalcontext
«««««««««Â
*occupationalaccomplishment,performance,roles
andresponsibilities
««««««««««Â
*variousoccupationalpatternsandareas«««««««««««««««
*occupationalidentity,controllabilityandmanageability«««
*strenuousandrestfuloccupations««««««««Â
*timespent,timeuse,timepressure,paceand/orrhythm«««««««««
nOB/LBinstruments2312002430020121
17181920212223242526272829303132
Biologicalneed««««««
Determinantofhealth«««««««««Â«Â««
Determinantof,oressentialfor,lifesatisfaction«Â
Dynamicstateandon-goingprocess«««««««««ÂÂ
Engagementinmeaningfuloccupations«««««««
Equilibriumandcongruenceamongoccupations«««««Â««
Subjectiveandindividual«««««Â«
*abilitiesandrestrictionstoadaptoccupations««««««Â«
*social,physicalandmentalwellbeing«
*capabilitiesandchallenges««««««««««Â«
*caringforoneselfandothers««««Â
*chosenandobligatoryoccupations«««««Â«
*harmonyandconflictamongoccupations«««««
*occupations(more/less)meaningfulfortheindividual
andsocio-culturalcontext
«««««««ÂÂ
*occupationalaccomplishment,performance,
rolesandresponsibilities
««««««««Â«
*variousoccupationalpatternsandareas««««««««««Â««
*occupationalidentity,controllabilityandmanageability«Â«
*strenuousandrestfuloccupations«««««««««
*timespent,timeuse,timepressure,paceand/orrhythm«««««««««Â«
nOB/LBinstruments000010200011/10110
(continued)
Du¨r et al. 7

5. Table1.Continued.
Categories
Referencesofarticlesonlifebalance
333435363738394041424344454647
Biologicalneed
Determinantofhealth«ÂÂÂÂÂÂÂ
Determinantof,oressentialfor,lifesatisfactionÂÂÂÂÂ
Dynamicstateandon-goingprocessÂÂÂÂÂÂ
EngagementinmeaningfuloccupationsÂÂ
Equilibriumandcongruenceamongoccupations«Â
SubjectiveandindividualÂÂÂÂ
*abilitiesandrestrictionstoadaptoccupationsÂ
*social,physicalandmentalwellbeing«Â
*capabilitiesandchallengesÂÂÂÂÂÂÂÂÂÂ
*caringforoneselfandothersÂÂ
*chosenandobligatoryoccupations«
*harmonyandconflictamongoccupationsÂÂÂ
*occupations(more/less)meaningfulfortheindividualand
socio-culturalcontext
ÂÂÂÂÂÂÂÂÂÂ
*occupationalaccomplishment,performance,rolesandresponsibilities«ÂÂÂ
*variousoccupationalpatternsandareas«ÂÂÂÂÂÂÂÂÂ
*occupationalidentity,controllabilityandmanageabilityÂÂÂÂÂÂÂÂÂÂÂÂ
*strenuousandrestfuloccupations«Â«Â
*timespent,timeuse,timepressure,paceand/orrhythmÂÂÂÂÂÂÂÂÂÂÂÂÂÂ
nOB/LBinstruments100000011100000
OB:occupationalbalance;LB:lifebalance;«:describedinthedefinitionsofOB;Â:describedinthedefinitionsofLB;Â:describedinthedefinitionsofOBandLB;*:Abalanceof...;(No.):referenceofthearticle
foundintheliteraturesearchonLBandOB;n:number.
8 The British Journal of Occupational Therapy 78(1)

6. Within the definitions of occupational and life balance,
the following categories were identified at an almost equal
frequency: ‘determinant of health (occupational balance ¼
24; 75% vs. life balance ¼ 16; 76%), ‘occupational accom-
plishment, performance, roles and responsibilities’ (24; 75%
vs. 15; 71%), ‘time spent, time use, time pressure, pace and/or
rhythm’ (20; 63% vs. 15; 71%), ‘chosen and obligatory occu-
pations’ (10; 31% vs. 5; 24%), ‘capabilities and challenges’
(22; 69% vs. 13; 62%) and ‘subjective and individual’ (12;
38% vs. 7; 33%). ‘Biological need’ was mentioned in relation
to occupational balance only. While life satisfaction was fre-
quently quoted as being essential for life balance (6; 29%),
‘engagement in meaningful occupations’ was mainly related
to occupational balance (11; 34%). The categories ‘affective
experience’, a balance of ‘doing and being’, ‘social demands’
and ‘life projects’ were not considered for further analysis,
since only three or fewer articles mentioned them. Five occu-
pational balance articles used occupational balance syn-
onymously with life balance (16%) and 12 did so with
lifestyle balance (38%). More articles reported the develop-
ment or use of occupational balance instruments (18; 56%)
than life balance instruments (7; 33%), as shown in Table 1.
Instruments. In the 20 occupational and life balance instru-
ments, we were able to identify a total of 65 categories.
The instruments consisted of 251 items which were used
for further investigation. The instruments’ characteristics
are briefly described in Table 2.
Instruments’ coverage of the definitions
The instruments’ coverage of the definitions is depicted in
Table 3. Most often the instruments covered a balance in
‘various occupational patterns and areas’ (14; 70%), a bal-
ance of ‘time spent, time use, time pressure, pace and/or
rhythm’ and ‘equilibrium and congruence among occupa-
tions’ (both 12; 60%). Another frequently measured cat-
egory was a balance of ‘occupations (more and less)
meaningful for the individual and the socio-cultural con-
text’ (11; 55%). Sixteen (84%) of the 19 categories that
were identified in the definitions were also covered by the
instruments. The ‘Q sort pack’ (I-18) covered 13 categories
(68%). The ‘time structure questionnaire’ (I-6, TSQ)
(Bond and Feather, 1988), the ‘experiences of engagement
in patterns of daily occupations’ questionnaire (I-10)
(Ha˚ kansson et al., 2009), and the ‘occupational value
instrument with predefined items’ (I-17, OVal-pd)
(Eklund et al., 2003) covered eight categories each
(42%), which were also identified in the definitions.
Compared with their frequent use in articles, a balance
of ‘occupational accomplishment, performance, roles and
responsibilities’ and ‘capabilities and challenges’ were cov-
ered by few instruments (7; 35%, and 6; 30%, respect-
ively). A balance of ‘abilities and restrictions to adapt
occupations’ – for example to changed life circumstances
– was covered only once, by the ‘Q sort pack’ (I-18). The
categories ‘individuality and subjectivity’ and the ‘dynamic
state of occupational or life balance’ were not covered by
the instruments (items). Nevertheless, the category
‘individuality and subjectivity’ is covered by some of the
instruments due to the fact that they assess patients’ per-
spectives. The health determining effect of occupational
and life balance was covered by two instruments:
Wilcock’s ‘Questionnaire on involvement in occupations’
(I-14) (Wilcock, 1997) and the ‘Q sort pack’ (I-18).
Discussion
To our knowledge, this is the first study searching system-
atically for occupational and life balance instruments, and
exploring their coverage of existing definitions of occupa-
tional and life balance.
The results show that a balance of ‘various occupa-
tional patterns and areas’, as well as of ‘occupational
accomplishment, performance, roles and responsibilities’,
(89% and 75%, respectively) were the most frequent cate-
gories in the articles. The categories that were a balance of
‘various occupational patterns and areas’ and of ‘time
spent, time use, time pressure, pace and/or rhythm’ were
the most frequent dimensions covered by the instruments
(70% and 60%, respectively). This may relate to the fact
that these two categories are easier to measure than other
complex dimensions of occupational balance (Eklund
et al., 2010). Time is fundamental to how people organise
and structure their daily lives, and can therefore be linked
closely to occupation (Edgelow and Krupa, 2011).
However, in two previous qualitative studies, a balanced
use of time was not found to be meaningful concerning
occupational balance for people with a chronic disease,
such as rheumatoid arthritis or Crohn’s disease (Du¨ r
et al., 2014b; Stamm et al., 2009). Interestingly, the cat-
egory balanced ‘occupational accomplishment, perform-
ance, roles and responsibilities’ was found to be covered
by 35% of the instruments.
The category of ‘biological need’ was only identified in
occupational balance articles. Moreover, in a recent quali-
tative study (Wagman et al., 2012b) occupational balance
has been found to be a part of life balance. In order to
guide occupational therapists in their understanding of the
two constructs, further studies on potential differences or
similarities are suggested.
The health determining effect of occupational balance
has been reported frequently (Anaby et al., 2010a;
Backman, 2004; Sandqvist et al., 2005; Wilcock, 1997).
Surprisingly, even though occupational therapists are con-
vinced that occupational balance has a positive effect on
health (identified in 23 occupational balance articles,
72%), it was found to be only measured by two instru-
ments (Wilcock’s ‘Questionnaire on involvement in occu-
pations’ [I-14] and the ‘Q sort pack’ [I-18]). Nevertheless,
some of the studies included instruments that assess gen-
eral health. In order to investigate this effect and a poten-
tial link between occupation and health, instruments that
assess general health should be used in addition to occu-
pational balance instruments.
Another fundamental belief of occupational therapists
is that engagement in meaningful occupations is an essen-
tial part of occupational balance, as quoted frequently
Du¨r et al. 9

7. Table 3. Categories identified in the definitions of occupational and/or life balance covered by instruments to measure occupational and/
or life balance.
Categories of OB and LB definitions
Instrument number (see Table 2)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Biological need
Determinant of healthy
þ þ
Determinant of, or essential for, life satisfaction þ
Dynamic state and on-going process
Engagement in meaningful occupations þ þ þ
Equilibrium and congruence among occupationsy
þ þ þ þ þ þ þ þ þ þ þ þ
Subjective and individual
*abilities and restrictions to adapt occupations þ
*social, physical and mental wellbeing þ þ þ þ þ þ þ
*capabilities and challengesy
þ þ þ þ þ þ
*caring for oneself and others þ þ þ þ
*chosen and obligatory occupations þ þ þ þ
*harmony and conflict among occupations þ þ þ þ
*occupations (more/less) meaningful for the individual and the
socio-cultural contexty
þ þ þ þ þ þ þ þ þ þ þ
*occupational accomplishment, performance, roles and responsibilitiesy
þ þ þ þ þ þ þ
*various occupational patterns and areasy
þ þ þ þ þ þ þ þ þ þ þ þ þ þ
*occupational identity, controllability and manageability þ þ þ þ þ þ þ
*strenuous and restful occupations þ þ þ þ þ þ
*time spent, time use, time pressure, pace and/or rhythmy
þ þ þ þ þ þ þ þ þ þ þ þ
*: A balance of . . .; OB: occupational balance; LB: life balance; y
: core dimensions, indicating that these categories were identified in more than
two thirds of the articles; þ: category is covered by the specific instrument.
Table 2. Characteristics of the identified instruments which were used, developed or suggested to measure occupational or life balance.
I-No. Name and content No. Items
I-1 Personal project analysis: project elicitation list and cross impact matrix (CIM) (Anaby et al., 2010b) [OB] 13
I-2 Inter-goal relations questionnaire (IRQ) (Anaby et al., 2010b), [OB] 5
I-3 Satisfaction with balance of time spent on occupational areas and patterns (Backman et al., 2004) [OB] 1
I-4 Instrument of occupational balance (Bejerholm, 2010) [OB] 3
I-5 Profiles of occupational engagement for people with schizophrenia (POES) (Bejerholm and Eklund, 2006b) [OB] 9
I-6 Time structure questionnaire (TSQ) (Bond and Feather, 1988) [OB] 26
I-7 Satisfaction with daily occupations (SDO) instrument (Eklund, 2004) [OB] 9
I-8 Yesterday diaries on temporal occupational patterns of the last 24 hours (Eklund et al., 2010) [OB] 4
I-9 Three dimensions of occupational balance (Forhan and Backman, 2010) [OB] 3
I-10 Experiences of engagement in patterns of daily occupations questionnaire (Ha˚kansson et al., 2009) [OB] 8
I-11 Occupational balance item (also contained in the ‘experiences of engagement in patterns of daily occupations’ questionnaire)
(Ha˚kansson et al., 2011) [OB]
1
I-12 Occupational questionnaire (Smith et al., 1986) [OB] 4
I-13 Possible measures of occupational balance (Wagman et al., 2012a) [OB] 15
I-14 Two-pages questionnaire on involvement in physical, mental, social and rest occupations (Wilcock, 1997) [OB] 6
I-15 Occupation, what’s in it for me? (Wilson and Wilcock, 2005) [OB] 1/n.d.
I-16 Experience sampling methodology (ESM) (Csikszentmihalyi and Larson, 1987) [OB] 1/8
I-17 Occupational value instrument with predefined items (OVal-pd) (Eklund et al., 2003, 2009a) [OB] 26
I-18 Q sort pack (Wagman et al., 2012b) [OB, LB] 42
I-19 Meaningful activities and needs instrument (MAWNA) (Eakman, 2013) [LB] 21
I-20 Life balance inventory (LBI) (Matuska, 2012a) [LB] 53
I-No.: allocated number of the instrument; []: instrument was used or developed to assess occupational balance [OB] and/or life balance [LB],
respectively; n.d.: not described.
10 The British Journal of Occupational Therapy 78(1)

8. (34% of the articles) (Backman, 2004; Bejerholm and
Eklund, 2007). This belief is reflected by three instruments
which were found to assess ‘engagement in meaningful
occupations’ (‘Profiles of occupational engagement for
people with schizophrenia’ [POES, I-5, Bejerholm and
Eklund, 2006b], ‘Experiences of engagement in patterns
of daily occupations’ questionnaire [I-10] and Wilcock’s
‘Questionnaire on involvement in occupations’ [I-14]).
Additionally, another related category, a balance of ‘occu-
pations (more and less) meaningful for the individual and
for the socio-cultural context’, was found to be covered by
11 instruments (55%). This category could be a comple-
mentary issue to the measurement of engagement in mean-
ingful occupations.
In our study, we identified a gap between the definitions
and instruments of occupational and life balance. For
example, the dynamic state of occupational balance is not
covered by any instrument. Furthermore, there are several
categories which are frequently cited, but seldom assessed,
such as occupational balance as ‘determinant of health’
(72% of the articles, measured by 10% of the instruments)
or of a balance of ‘capabilities and challenges’ (70% of the
articles, measured by 30% of the instruments).
Wada et al. (2010) characterised balance with quantity,
congruence, fulfilment and compatibility. Wagman et al.
(2012a) found that occupational balance was related to
occupational areas, occupational characteristics and time
use. However, in the current study, the content of the def-
initions of occupational and life balance were categorised
in smaller units. This enabled the assignment of certain
articles to certain categories used in relation to occupa-
tional balance. Furthermore, the numerous categories
identified in the current project allowed a precise examin-
ation and statement on their coverage by existing occupa-
tional and/or life balance instruments. The numerous
categories identified in the current project allowed a pre-
cise examination and statement on their coverage by exist-
ing occupational and/or life balance instruments. Based on
the results of a systematic literature search, we were able to
give an overview about existing occupational and life bal-
ance instruments. Moreover, the findings of this study can
support occupational therapists and other health profes-
sionals in their selection of instruments to assess occupa-
tional or life balance in practice and in research. An
example are patients with rheumatoid arthritis: activity
limitations and participation restrictions can result in a
loss of meaningful activities, such as engaging in sports
or attending social activities (Forhan and Backman,
2010). Thus, occupational therapy interventions that
improve functioning support the (re-) establishment of a
balance between different occupations, such as self-care,
productivity, leisure and rest. This could be assessed with
one of the occupational balance instruments that cover the
category that is a balance of ‘various occupational pat-
terns and areas’. In addition, we suggest further research
to appraise other psychometric properties and thus com-
plement the information that is important in assisting the
choice of an appropriate instrument. The ‘TSQ’ (I-6), the
‘experiences of engagement in patterns of daily
occupations’ questionnaire (I-10) and the ‘OVal-pd’ (I-
17) covered eight categories each. The ‘Q sort pack’ (I-
18) covered 13 categories of the occupational and life bal-
ance definitions. Since instruments with few items are
more applicable for clinical use, we suggest the develop-
ment of a brief occupational balance instrument based on
essential aspects important to patients.
Strengths and limitations
We included only articles published in peer-reviewed sci-
entific journals. This could have limited the variety of the
different contents of the occupational and life balance def-
initions. Additionally, a search in different databases
could have led to other findings and the identification of
more occupational and life balance instruments. However,
PubMed, CINAHL and Web of Science appeared to cover
most peer-reviewed scientific journals relevant to occupa-
tional therapists or occupational scientists. Additionally,
original sources upon which the used occupational and/or
life balance definitions were based were not obtained.
However, they were included for further analysis within
the selected articles. Another limitation was that we did
not search explicitly for ‘occupational imbalance’ as a
related term. As it is unclear whether this is another
stand-alone concept or an aberration of occupational bal-
ance (Anaby et al., 2010a, 2010b), we decided not to look
specifically for this keyword. The inclusion of the term ‘life
balance’ seemed to be justified, since it is occasionally used
with regards to occupational balance in occupational ther-
apy literature (Backman, 2004). The fact that the meaning
categorisation was conducted by researchers who are also
occupational therapists could have had an impact. The
inclusion of researchers with other professional back-
grounds into this process may have led to different find-
ings. Moreover, the critical appraisal of current evidence
of instruments’ validities could have provided additional
important information. The detailed presentation of the
results increased the comprehensibility of the findings.
Based on these findings, the need for further research,
such as an analysis of the psychometric properties of the
identified occupational and life balance instruments,
becomes clear. Additionally, empirical data as well as
Delphi exercises could be used to find consensus on the
definition of occupational balance.
Conclusion
The current definitions of occupational and life balance
used in scientific literature could be condensed to 19 cate-
gories, of which 16 are covered by 20 identified occupa-
tional and life balance instruments. Their examination can
support occupational therapists, other health profes-
sionals and health researchers to know which instruments
are already used or developed to measure occupational
balance. In addition, the findings of this study can assist
these people in their selection of instruments when assess-
ing the need for, or evaluating the effect of interventions
addressing, occupational balance.
Du¨r et al. 11

9. Key findings
Definitions of occupational balance contained 19 cate-
gories. A total of 20 instruments were explored.
Together they covered 16 (84%) categories. The category
of a balance of ‘various occupational patterns and areas’
was covered most frequently.
What the study has added
This study provides an overview of the instruments that
measure occupational balance. Knowing which instru-
ments cover which dimensions can support occupational
therapists to choose between occupational balance
instruments.
Acknowledgements
We would like to thank Alexa Binder for conducting the content ana-
lysis of the articles. Furthermore, we want to thank the native speakers
Andrea Jordan and Yvonne Schro¨ der for proofreading, and Stefanie
Haider for the discussions on the meaning categorisation analysis.
Research ethics
Ethics approval was not required for this study.
Declaration of conflicting interest
None declared.
Funding
This research was partly funded by a restricted grant from the
Austrian Science Fund (FWF): [P21912-B09]. The FWF had no influ-
ence on the content of the manuscript.
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Appendix 1. Flow diagram: article selection process based on a systematic literature search
14 The British Journal of Occupational Therapy 78(1)

12. Appendix 2. Article numbers
Appendix 3. Percentage of the numbers of articles describing a certain category
Categories of OB and LB definitions
Percentage of articles
All OB LB
Biological need 16 22 0
Determinant of healthy
74 71 67
Determinant of, or essential for, life satisfaction 16 3 33
Dynamic state and on-going process 58 61 44
Engagement in meaningful occupations 23 32 0
Equilibrium and congruence among occupationsy
67 54 83
Subjective and individual 35 39 33
*abilities and restrictions to adapt occupations 33 45 0
*social, physical and mental wellbeing 14 6 33
*capabilities and challengesy
70 68 61
*caring for oneself and others 26 8 4
*chosen and obligatory occupations 35 32 33
*harmony and conflict among occupations 26 29 11
*occupations (more/less) meaningful for the individual and the socio-cultural contexty
67 54 72
*occupational accomplishment, performance, roles and responsibilitiesy
79 74 89
*various occupational patterns and areasy
91 94 72
*occupational identity, controllability and manageability 40 23 67
*strenuous and restful occupations 51 54 33
*time spent, time use, time pressure, pace and/or rhythmy
74 64 72
*: A balance of . . .; OB: occupational balance; LB: life balance; All: percentage of all articles; y
: core dimensions, indicating that these categories
were identified in more than two-thirds of the articles.
No. References of OB articles No. References of OB articles No. References of LB articles
1 (Anaby et al., 2010b) 17 (Koome et al., 2012) 33 (Eakman, 2013)
2 (Backman, 2004) 18 (Ludwig et al., 2007) 34 (Ha˚kansson et al., 2006)
3 (Backman et al., 2004) 19 (McGuire et al., 2004) 35 (Ha˚kansson and Matuska, 2010)
4 (Bejerholm, 2010) 20 (Morgan 2010) 36 (Johansson et al., 2012)
5 (Dubouloz et al., 2004) 21 (Ottenvall Hammar and Ha˚kansson, 2013) 37 (Lisson et al., 2013)
6 (Du¨r et al., 2014a) 22 (Pettican and Prior, 2011) 38 (Majnemer, 2010)
7 (Edgelow and Krupa, 2011) 23 (Sandqvist and Eklund, 2008) 39 (Matuska, 2012a)
8 (Eklund et al., 2009b) 24 (Stamm et al., 2004) 40 (Matuska, 2012b)
9 (Eklund et al., 2010) 25 (Stamm et al., 2009) 41 (Matuska and Christiansen, 2008)
10 (Eriksson et al., 2010) 26 (Wada and Beagan, 2006) 42 (Matuska et al., 2013)
11 (Eriksson et al., 2011) 27 (Wagman et al., 2012a) 43 (Pentland and McColl, 2008)
12 (Forhan and Backman, 2010) 28 (Wagman et al., 2012b) 44 (Piskur et al., 2002)
13 (Gibbs and Klinger, 2011) 29 (Westhorp, 2003) 45 (Reece et al., 2009)
14 (Ha˚kansson et al., 2009) 30 (Wilcock, 1997) 46 (Wada et al., 2010)
15 (Ha˚kansson et al., 2011) 31 (Wilson and Wilcock, 2005) 47 (Wagman et al., 2011)
16 (Jonsson and Persson, 2006) 32 (Argentzell et al., 2012)
LB: life balance; No.: number; OB: occupational balance.
Du¨r et al. 15