Psychometric properties of the Spanish version of the Engagement in Meaningful Activities Survey in people with serious mental illness

Abstract

Introduction

Facilitating engagement in meaningful activities is a key intervention in the recovery process of people with serious mental illness. This study validates the use of the Engagement in Meaningful Activities Survey in the Spanish mental health population for the purposes of measuring such engagement.

Method

Two hundred and ninety-five people with serious mental illness (68.3% were male; M = 47.5, SD = 9.7 years) participated voluntarily and anonymously in the study. All gave written informed consent. A translation into Spanish and back-translation to English was made. Reliability and validity of the Engagement in Meaningful Activities Survey was assessed by the internal consistency, temporal stability and dimensionality of the scale.

Results

The Cronbach’s alpha of the Engagement in Meaningful Activities Survey scale was 0.91 and the intraclass correlation coefficient was 0.76. Confirmatory factor analysis revealed a two-factor structure of the scale (χ² = 93.906, p < .001; comparative fit index = .96, Tucker–Lewis index = .95, root-mean-square error of approximation (90% confidence interval) = .05 (.03–.07) and standardized root mean square residual = .04). All the items showed significant standardized factor loadings above .59. Correlation between the two factors was .97 (p < .001).

Conclusion

The instrument could be useful for assessing engagement in meaningful activities and helpful for recovery process interventions focused on enhancing community adjustment in people with serious mental illness.

Keywords

Engagement in Meaningful Activities Survey (EMAS)psychometric properties people with serious mental illness (PSMI)community adjustment social functioning occupational therapy

Introduction

People with serious mental illness (PSMI) experience problems functioning independently within the community, showing social and occupational limitations. Several authors have stated that the deficit in psychosocial functioning of PSMI includes anhedonia, few interpersonal contacts, lack of social participation and/or poor social support (Kingston et al., 2018; Sweet et al., 2018). The explanation for this poor social adjustment in PSMI involves a complex and dynamic interaction between several clinical and sociocultural factors, such as the level and the type of clinical symptomatology, house conditions, low income or stigma (Killaspy et al., 2014).

In PSMI there is an alteration in time-use patterns (Chugg and Craik, 2002), showing a decrease in time spent on occupational areas of self-care, leisure activities or work, and spending a greater part of their time being quiet and isolated at home (Harvey et al., 2006; Krupa et al., 2003). These deficits in social functioning and participation have been related to a decrease in wellbeing, quality of life and life satisfaction (Goldberg et al., 2002; Kingston et al., 2018). It is well known that effective interventions to improve social adjustment in PSMI, such as the facilitation of interpersonal relationships or social support (Kinn et al., 2014; Sweet et al., 2018), also increases wellbeing, quality of life and life satisfaction in PSMI (Browne et al., 2017; Coffey et al., 2019).

In fact, what all these interventions have significantly in common is that they are able to provide meaning and value to daily life (Mee et al., 2004). PSMI obtain meaning when they have a sense of control, a structure in their daily occupations, satisfaction with daily occupations, and maintain mental and social health (Bronowski et al., 2017). Interventions that contribute to the development of identity, purpose and life-sense are closely related to the development of the so-called personal recovery process in PSMI (Doroud et al., 2015).

The personal recovery process in PSMI implies having a life project beyond clinical symptoms or psychosocial functional deficits. For that, it is necessary to have a sense of self-life, which is in turn associated with engagement in meaningful activities undertaken in a specific social context; such activities not only lead to competence or pleasure, but are also valued by others (Hammell, 2004). A person’s social situation directly influences their health, quality of life and wellbeing (Sweet et al., 2018) and, in the specific case of PSMI, the improvement of social function, and the ability to construct significant interpersonal relationships to achieve social support and wellbeing, is essential in order to encourage the personal recovery process (Tanaka and Davidson, 2015).

In our geographical area, one of the public services targeted towards PSMI with difficulties in achieving social and community adjustment is the provision of social clubs (Generalitat de Catalunya, 2015). As their main goal, these entities encourage personal recovery via the promotion of community functioning through engagement in meaningful activities. However, we have not found in the literature to date any reviewed data concerning the assessment of engagement in meaningful activities in PSMI under recovery treatment in specific social health services in Spain.

Literature review

Engagement in meaningful occupations is a key outcome of occupational therapy intervention (Gallagher et al., 2015; Hammell, 2004), and is a key practice employed by occupational therapists in the personal recovery process of PSMI (Doroud et al., 2015; Harrison et al., 2016). Nevertheless, the meaning of a given activity is highly variable across individuals and could be influenced by several factors, such as age, personal values, goals, sources of satisfaction, and cultural and social factors (Yerxa, 1998). However, a unitary definition of what is a meaningful activity has not been achieved, and therefore most authors consider a meaningful activity as any activity identified by an individual as meaningful; that is, actions that the individual considers important in that they are goal-directed or give one’s life purpose. Therefore, the concept of meaningful activities encompasses a great diversity of activities, potentially different for each person (Eakman et al., 2010a, 2010b).

This fact widely concerns the objective assessment of meaningful activities and controversies do exist over how such concepts can be best operationalized (Eakman, 2012; Harrison et al., 2016; Townsend and Polatjko, 2007). Several methods have been used to assess meaningful activities: self-reported or qualitative data, such as the frequency of engaging in activities; the importance to the individual associated with undertaken activities; barriers to realizing activities; or the pleasure or value related to the engagement in a specific activity (Ciro and Smith, 2015; Eakman et al., 2010a, 2010b; Fernández-Ballesteros et al., 2001). However, over the last few years several psychometrically validated instruments have been developed for these purposes, including the Canadian Occupational Performance Measure (in which people self-categorized meaningful activities into five categories: personal care, physical, quiet leisure, productive and social, see Carswell et al., 2004), or EMAS (Goldberg et al., 2002).

EMAS was developed initially and specifically for PSMI (Goldberg et al., 2002); however, recently its application has also been expanded to other populations, such as older adults (Eakman, 2012), university students (Eakman, 2011) and people with chronic conditions living in a low-income community (Ciro and Smith, 2015). It specifically assesses several meanings in line with the perspective of consilience, leading to several perspectives of meaning linked to convergent aspects of human action and motivation (Eakman, 2011). Meaning measured by EMAS includes the agreement between the activities, values and needs of the person; those undertaken activities that lead to a feeling of competence; and the relevance for the individual of a given activity according to their specific social or cultural group (Goldberg et al., 2002). The EMAS has been translated into several languages, including French (Lacroix et al., 2018) and Polish (Bozek and Tokarz, 2017), and it is currently used in several countries, suggesting that it could be used in different cultural settings.

The aims of this study were to validate the use of this instrument for measuring meaningful engagement in Spanish PSMI and to assess the level of engagement in meaningful occupations, by means of EMAS, in PSMI who are included in social club resources.

Method

Research design

The present study aimed to translate and provide reliability and validity evidence of the scores of the EMAS scale for its use in Spanish PSMI. For this study, a translate-back-translation process and test–retest reliability was carried out. Two assessments were performed with a difference of 7–15 days.

The study was approved by the committee of Salut Mental Catalunya. All prospective participants were informed by oral and written information. All participation was voluntary, and those who decided to participate were contacted by a third party social club professional and gave their written consent prior to their inclusion in the study.

Sample

The participants of this study were PSMI using social club resources in Catalonia. Eleven social clubs participated in the study, amounting to a total potential sample of 330 participants. The inclusion criteria were people included in the social club regardless of their clinical diagnosis and aged between 18 and 65 years. The exclusion criteria were: people who presented a clinical imbalance that requires admission to acute units; those with linguistic difficulties and those who expressed a wish not to participate in the study. The clinical diagnosis was confirmed by a psychiatric report based on DSM-IV-TR criteria (American Psychiatric Association, 2000), which was also a necessary precursor to being admitted to a social club. For this study we consider four main categories: psychotic diagnostic categories including schizophrenia, schizoaffective disorder or schizophreniform disorder; affective categories including depression or bipolar disorder; anxiety categories including panic disorder, general anxiety disorder or obsessive-compulsive disorder; and an addictive category that included all substance use disorders except nicotine and caffeine use disorders.

Instruments

Information about age, gender, civil status, educational level, living circumstances and employment was collected.

The EMAS (Goldberg et al., 2002) is a participant survey developed specifically for people with serious mental illness, to measure the extent of their engagement in meaningful activities. It is a 12-item self-report instrument that measures the extent to which an individual’s activities align with values, have value within their social context and demonstrate the person’s perception of mastery of meaningful activity. Items are answered using a five-point Likert scale ranging from 1 = never to 5 = always. The maximum score is 60, with scores close to 60 representing a higher amount of meaning in one’s daily activities. Factor analysis indicated a two-component structure: social experiential and personal competence (Eakman et al., 2010a). In the general population, the internal consistency (α = 0.89) and test–retest reliability (r = 0.56) were acceptable to good. When testing this measure on a population of participants with serious mental illness, good evidence of face and construct validity and test–retest reliability at 0.69 were obtained (Goldberg et al., 2002).

Procedure

Translation and back-translation process

The first step was to do the translation and back-translation process. The research team made contact with the authors of the scale to obtain their consent to be translated and validated for use in the Spanish context. The author provided the original version in English, subsequently initiating the translation and back-translation process (Muñiz et al., 2013).

A native English speaker translated the original version of the EMAS into Spanish. Once a literal translation had been obtained, some words were adapted according to a comprehensive cultural validation done by five professionals, five PSMI and five members of the general population. The words adapted were in item 4: ‘plenitude’ for ‘sense of accomplishment’ as work well done was completely satisfying. In item 8 the word ‘agradable’ was used for ‘gives me pleasure’, in order to differentiate it from item 11: ‘sense of satisfaction’; in this case we used the word ‘satisfacción’. After a definitive Spanish version was accepted, this was then back-translated into English. Once the back-translation had been completed it was sent to the original author of the scale, who did not add any modifications.

Data collection

Data collection was carried out by professionals working in the social clubs: occupational therapists or social educators. All the professionals participating in the study were well trained in the application of the instrument. The professionals facilitated the Spanish version to participants individually for them to perform the self-report. Nevertheless, professionals remained close by in case participants had any questions. There were no questions in the application of EMAS. Once the person answered, a time interval of 7–15 days was recorded in order to do the retest, when the professional gave another copy of the instrument and followed the same procedure as the first time. Data were collected during 2015.

Data analysis

Data analysis was done using SPSS version 19. Evaluation of the reliability of the questionnaire and its temporal stability was calculated through the intraclass correlation coefficient 8ICC. Mplus version 6 (Muthén and Muthén, 1998–2011) was used to perform confirmatory factor analysis (CFA). Because univariate and multivariate kurtosis were found, we applied the Satorra–Bentler scaled ML correction (Satorra and Bentler, 1988) to adjust the model chi-square. Missing data (less than 3%) was handled with full information maximum likelihood. It is known that chi-square testing can be sensitive to the sample size; therefore, model fit was evaluated also based on the comparative fit index (CFI), the Tucker–Lewis index (TLI), the root-mean-square error of approximation (RMSEA) and the standardized root mean square residual (SRMR). In line with the recommendations suggested by Hu and Bentler (1999), CFI and TLI values over .95 and RMSEA values below .05 indicate good fit to data. In addition, SRMR values are expected to be below .08.

Results

Sample description

Of the 330 potential participants, 20 did not fulfil inclusion criteria, of whom 13 showed linguistic difficulties and seven were in a destabilized state that required admission to acute units. Of the remaining 310 PSMI, 300 agreed to participate in the study; of these, five later withdrew from the study. The final sample included 295 participants (68.3% male and 32.7% female) with mean age M = 47.5 (SD = 9.7) years old. Regarding civil status, 79.1% were single, 53.3% lived with their parents. In terms of education, 51.5% reported having successfully completed up to and including primary education, with a further 35.2% completing high school and 7% completing university. Unemployment in this sample was 92.5%, while 6.2% worked in a regular job and 1.3% in a supported work environment. Disability allowance was received by 61.1%, 33% received social security benefit, 5% received unemployment benefit and 0.9% had no income. Clinically, 72.2% had been diagnosed with a psychotic disorder, 19.3% with an affective disorder, 4.5% with an addictive disorder and 2.7% with anxiety disorder (see Table 1 for all socio-demographic and clinical features).

Table 1.

Socio-demographic and clinical information.

Type of information	Percentage
Gender
Male	68.3
Female	31.7
Civil Status
Single	79.7
Married	8.4
Domestic partnership	11.5
Widow	0.4
Diagnostic 1
Psychotic disorders	72.2
Affective disorders	19.3
Addictive disorders	4.5
Anxiety disorders	2.7
Others	1.3
Diagnostic 2
Comorbidity	63.5
Personality disorders	23.8
Mental retardation	12.7
Educational level
Primary school	51.5
High school	35.2
University	7.0
None	5.7
Unknown	0.4
Cohabitation
Alone	17.6
First degree relatives	53.3
Second degree relatives	1.8
Partner	4.0
Partner with kids	7.0
Public house services	16.3
Work status
Work	6.2
Unemployment	92.5
Sheltered work	1.3
Benefits
Disability allowance	61.1
Social security benefit	33.0
Unemployment benefit	5.0
Without income	0.9
Age
Mean	SD
47.49	9.68
EMAS score
Mean	SD
43.85	9.56

EMAS: Engagement in Meaningful Activities Survey

Internal consistency and temporal stability

The Cronbach’s Alpha of the EMAS scores on our sample was 0.91, which represents a high value in internal consistency for the instrument items. The intraclass correlation coefficient was 0.76, indicating a good temporal stability of the instrument.

Factorial structure

We conducted a confirmatory factor analysis to test if the Spanish version of the EMAS followed the same structure as the original version. A two factor model was tested, with the first five items of the scale loading on the personal competence component (PCC) and the remaining items loading on the social-experiential component (SEC). The results obtained (χ2 = 93.906, p < .001; CFI = .96, TLI = .95, RMSEA (90% CI) = .05 (.03–.07) and SRMR = .04) suggested a good fit of the model to the data (Satorra and Bentler, 1988). Table 2 shows all the items with their standardized factor loadings, all of them significant and above .59. The correlation among the two factors was .97 (p < .001).

Table 2.

Engagement in Meaningful Activities Survey (EMAS) items and their confirmatory factor loadings.

	Standardized factor loadings
Items^a	Social-experiential component	Personal competence component
1. Las actividades que hago me ayudan a cuidarme (p.ej. mantener la higiene, administrarme el dinero).		.56
2. Las actividades que hago reflejan el tipo de persona que soy.		.64
3. Las actividades que hago expresan mi creatividad.		.62
4. Las actividades que hago me ayudanaalcanzaralgo, y esto me da unasensación de plenitud.		.68
5. Las actividades que hago hacen que me sientacompetente.		.77
6. Los demás valoran las actividades que hago.	.59
7. Las actividades que hago ayudan a los demás.	.61
8. Las actividades que hago me resultan agradables.	.73
9. Las actividades que hago me dan sensación de control.	.73
10. Las actividades que hago me ayudan a expresar mis valores personales.	.74
11. Las actividades que hago me dan una sensación de satisfacción.	.70
12. Las actividades que hago tienen el punto justo de reto.	.71

Introductory language to the EMAS and rating scale was: ‘A continuación hay una lista de informaciones sobre sus actividades. Lea con atención cada una de estas afirmaciones y coloque una X en el número que describe mejor en qué medida se le aplica esta afirmación de manera general, considerando el 1 como nunca y el 5 como siempre. Tómese su tiempo y trate de responder con la mayor precisión posible’.

Discussion and implications

The results of our study indicate that the EMAS shows good psychometric properties, with very high reliability, moderate to high temporal stability and very high internal consistency. The results of the psychometrical parameters were better than those obtained with the original scale in previous studies (Eakman et al., 2010a, 2010b; Goldberg et al., 2002), suggesting that the validation of the instrument in people with a mental health disorder is adequate and that this instrument could be useful in assessing engagement in meaningful activities in this population. The average scores of the scale were similar or slightly higher than those obtained in other studies carried out in the mental health population (Goldberg et al., 2002; Zimolag and Krupa, 2009). Potential differences could be explained by the mainly heterogeneous nature of the samples studied, and the fact that in our study all participants were in the recovery process, which could lead to a greater meaningfulness of the activities done.

Factor analysis confirms the two components of the survey (Eakman et al., 2010a), the SEC and the PCC. As in the original analysis, the SEC component is related to the socially situated perceptions of meaning (valued by others, help others) and the PCC is related to personal experiences of competence or accomplishment, expression of the self and personal creativity. This result confirms the usefulness of the instrument in assessing what has been termed the ‘ways to meaning’ variable (Eakman et al., 2010a, 2010b), allowing exploration of the person’s preference for either the social component or for the personal component and its potential relationships with other factors, such as life satisfaction (Eakman et al., 2010a, 2010b), health related quality of life (Goldberg et al., 2002), depression and boredom (Eakman, 2011), or global functioning (Zimolag and Krupa, 2009).

These findings suggest that the application of EMAS could be highly relevant in assessment of the personal recovery processes from mental health problems, as a potentially useful tool in facilitating the achievement of therapeutic goals in all services focused on and favouring community adjustment through rehabilitation and psychosocial interventions that promote and foster the experience of personal recovery, favouring engagement in meaningful activities (Coffey et al., 2019; Doroud et al., 2015; Harrison et al., 2016).

More specifically, the two components of EMAS should allow the planning of therapeutic goals in such activities that have meaning for the individuals, according to their preference, and consequently favouring their satisfaction, or emphasize such areas with low levels of perceived meaning in order to facilitate social adjustment. In the case of social club service, the SEC could be very useful in developing individual plans favouring community functioning. Moreover, the EMAS could also be used to assess occupational engagement in meaningful activities, thus creating an intervention that entails fully occupational therapy functions in psychiatric rehabilitation (Doroud et al., 2015; Harrison et al., 2016).

Limitations and future research

The study has two main limitations, one regarding features of the sample and the other the design of the study. In the case of the sample, it is wholly formed by users of social clubs, and although several psychiatric diagnoses are represented, all people were in the recovery process in a specific social inclusion resource. It would be necessary to study the EMAS in new samples of different social and cultural contexts to verify the variability of the scores and the generalizability of the instrument. Moreover, longitudinal studies, in addition to cross-sectional ones and including other measures related to wellbeing and clinical and social functioning, should be carried out in order to analyse the evolution and the relevance of engagement in meaningful activities in the recovery process of people with mental health problems. Furthermore, it would be interesting to explore the factorial analysis of the model as a unidimensional factor, since it could allow for the exploration of social constructs underlying the personal recovery process in PSMI.

Conclusion

The EMAS in the Spanish sample has proven to be a valuable tool in assessing the meaningfulness of activities and is able to be used in the therapeutic process in recovery, mainly in those resources addressing the social inclusion of people with mental health problems. Moreover, the psychometric properties of EMAS showed that this instrument could also be used for research purposes, suggesting that it could be useful in facilitating assessment of occupational therapy interventions in PSMI.

Key findings

The Spanish version of EMAS shows good psychometric properties in PSMI, being an adequate instrument in assessing engagement in activities in this collective.

The Spanish version of EMAS shows the same factor structure as the original, confirming the usefulness of the instrument in PSMI in assessing both the person’s preference for social activities and their feelings of personal competence in a social interaction.

EMAS could be a useful instrument in assessing occupational therapy interventions in the recovery process of PSMI in several cultural contexts.

What the study has added

This study has validated the Spanish version of EMAS in PSMI and its potential usefulness in assessing occupational therapy interventions in the recovery process of this population.

Footnotes

Acknowledgements

We would like to thank the following organizations for their participation, without which the study would not have been possible: clubs sociales, which form part of the range of services of the Department of Employment, Social Affairs and Families: Club Social Aidar (Igualada), Club Social Cap Endavant (Barcelona), Club Social El Llorer (El Vendrell), Club Social El Turó (Vilafranca del penedés), Club Social Espai 3 (Cornellà), Club Social Gramenet (Santa Coloma de Gramenet), Club Social La Bruixola (Lleida), Club Social La Llum (Mollet), Club Social MentsObertes (Barcelona), Club Social Mosaic (Manresa) and Club Social Tu Tries (Mataró). We also wish to thank Andrew Dodd for his support in helping translate the text into English.

Research ethics

Ethical approval was obtained from the committee of Salut Mental Catalunya (SM001-2015).

Consent

All participants provided written informed consent before participating in the study.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship and publication of this article.

Funding

The authors received no financial support for the research, authorship and publication of this article.

Contributorship

Gemma Prat, Francisco Muñoz and Arantxa Ribot researched literature, applied for ethical approval and contributed to the development of the data. Arantxa Ribot and Sílvia Recoder contributed to the methodology of the project and the statistical analysis plan. Sílvia Recoder carried out the statistical analysis, and all authors interpreted the data. Gemma Prat wrote the first draft of the manuscript. All authors reviewed and edited the manuscript and approved the final version.

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