Abstract
Introduction
Occupational balance (OB) is related to many health indicators, including quality of life. The Occupational Balance Questionnaire (OBQ11) was developed to measure OB, and to date, no Arabic translations of the questionnaire exist. The aim of the study was to describe the translation process of OBQ11 to Arabic and to evaluate its content validity, internal consistency, construct validity, and convergent validity.
Methods
OBQ11 was translated to Arabic (OBQ11-A) following standard guidelines. Content validity feedback was obtained from ten Arabic-speaking occupational therapists and in a cognitive debriefing with seven volunteers. In addition, OBQ11-A and the Family Quality of Life Survey-2006 were administered to 67 Arabic-speaking participants from a larger study about OB among parents.
Results
High level of agreement was found on the content of OBQ11-A from the occupational therapists. Cognitive debriefing interviews indicated that OBQ11-A was easy to understand. Cronbach’s alpha for the total OBQ11-A score was 0.864 indicating good internal consistency. Exploratory factor analysis showed acceptable factor loadings for all items. The total scores showed positive statistically significant associations with Family Quality of Life Scores (r = 0.561, p < 0.001).
Conclusions
OBQ11-A may prove useful for assessing OB in Arabic-speaking populations. Further research is needed to establish its reliability.
Introduction
Occupational balance (OB) is one of the core concepts in occupational therapy (OT), and it has been found that quality of life can be improved by promoting it (Park et al., 2020). OB is related to quality of life, overall health and well-being, life satisfaction, and reduced stress levels (Håkansson et al., 2009; Håkansson and Ahlborg, 2016; Håkansson et al., 2020, 2021; Håkansson and Lexén, 2021; Wagman et al., 2019, 2020; Wagman and Håkansson, 2014a, 2014b; Wilcock et al., 1997; Yu et al., 2018). Even though the concept of OB was mentioned in Meyer’s articulation of the philosophy of occupational therapy (Meyer, 1977), standardized tools for measuring OB were not developed until much later. Three instruments that measure OB explicitly currently exist in the literature are as follows: The revised Occupational Balance Questionnaire [(OBQ11] (Håkansson et al., 2019b, 2019c), Satisfaction with Daily Occupations - Occupational Balance [SDO-OB] (Eklund and Argentzell, 2016), and the Occupational Balance Questionnaire [OB-QUEST] (Dür et al., 2014).
The Occupational Balance Questionnaire (OBQ) and the revised OBQ11 have been widely used by researchers to measure OB ever since its development (Borgh et al., 2018; Gunal et al., 2021; Håkansson et al., 2019a, 2019b, 2021; Håkansson and Lexén, 2021; Kassberg et al., 2021; Magnusson et al., 2020; Wagman et al., 2016). The instrument, originally developed in Swedish, has been translated to a number of other languages (Gomez, 2017; Günal et al., 2020; Uhrmann et al., 2019; Yu et al., 2019), but not as yet to the Arabic language. The aim of the present study was thus to describe the translation process of the OBQ11 to Arabic and to evaluate its content validity, internal consistency, construct validity, and convergent validity.
Literature review
The original OBQ was developed by Wagman and Håkansson (2014a, 2014b) based on the definition of OB as an individual’s perception of having the right amount and variety of occupations in one’s daily occupational pattern (Wagman et al., 2011). The framework used by the authors during the development of the OBQ had different elements which are as follows: variation in the occupational pattern (balance between work, home, family, leisure, rest, and sleep; physical, social, mental, and restful occupations; obligatory/voluntary occupations; energy-giving/energy-taking occupations; doing things for others/for oneself); amount of each occupation (satisfaction with time spent and number of occupations); total number of occupations in relation to the available resources with respect to time and opportunities (Wagman and Håkansson, 2014a, 2014b).
The original OBQ had 13 items to be rated on a 6-point Likert scale with summed scores ranging from 0 to 65 with high scores indicating a high level of OB (Wagman and Håkansson, 2014a, 2014b). The number of items was reduced to 11 in the revised version and a 4-point Likert scale was utilized (OBQ11) with summed scores ranging from 0 to 33 based on Rasch analyses (Håkansson et al., 2020). The OBQ was translated from Swedish to English and was found to be easy to understand with good internal consistency and moderate test–retest reliability in a non-representative Canadian sample (Yu et al., 2018). Uhrmann et al. (2019) developed a Norwegian version of OBQ11 and reported that it was feasible and had good face validity. Günal et al. (2020) translated OBQ11 to Turkish and demonstrated its reliability and validity in a sample of 58 Turkish participants.
Arabic is the primary language in the countries from the geographical region comprising the Middle East and North Africa, including The State of Qatar. With the recent expansion of healthcare and rehabilitation in Qatar, OT plays a significant role in the field of rehabilitation. A translation and cultural adaptation of OBQ11 would be a valuable contribution to the field of OT in Qatar as well as in the other Arabic-speaking countries in the world.
Materials and methods
The present study describes the process of translation of OBQ11 from English to Arabic and reports its initial psychometric properties. The study was conducted in three stages. First, OBQ11 was translated from English to Arabic, and then field testing of OBQ11-Arabic (OBQ11-A) was performed with the aim of establishing its content validity. In the third and final stage, data from the Arabic-speaking participants from a larger study on OB among parents living in Qatar that included both English- and Arabic-speaking participants were used to examine the internal consistency, construct validity, and convergent validity of OBQ11-A. The purpose of that study was to compare the level of OB among parents of typically developing children and parents of children with disabilities. The participants in that study provided written informed consent, and ethical approval was obtained from the institutional review boards of Nova Southeastern University (IRB #: 2019–2045) and Hamad Medical Corporation (MRC #: 01–18-465). Figure 1 provides a graphic of the three stages in the study and the steps within each stage. Translation and initial validation of Occupational Balance Questionnaire-A.
Evaluation instrument
OBQ
The revised occupational balance questionnaire (OBQ11) is an 11-item self-rated questionnaire for investigating a person’s perception of OB in terms of having the right amount and variation of occupations in everyday life (Håkansson et al., 2020). Each item in OBQ11 is rated on a 4-point Likert scale ranging from 0 to 3. The total score thus ranges from 0 to 33 with higher scores indicating higher OB. Individual items can also be analyzed separately. Psychometric properties for OBQ including content validity, internal consistency, and test–retest reliability for the original OBQ were found to be good (Wagman and Håkansson, 2014a, 2014b). The OBQ11 was found to be valid and satisfied the measurement criteria defined by the Rasch model (Håkansson et al., 2020). OBQ11 is currently available in several language versions that have shown acceptable psychometric properties in preliminary studies (Günal et al., 2019; Uhrmann et al., 2018).
Stages of the study
The study took place in three stages. Each stage is described in detail (Figure 1).
Stage 1: Translation
The translation of the OBQ11-A was performed in accordance with the guidelines suggested by Beaton et al. (2000). Each step in the translation process is described.
Step I: Forward translation
Two translators, both of whom had Arabic as their mother tongue, carried out independent forward translations of the OBQ11. One was an occupational therapist with background knowledge about the concepts used in OB. The second translator, who was uninformed about the concept of OB, was a professor in translation studies.
Step II: Synthesis of the translation
A panel comprising forward translators and the first author were convened to produce a common translation based on consensus, which was tentatively named as OBQ Arabic—draft.
Step III: Back translation
Two translators who were totally blind to the translations in Stage 1 provided backward translations of the draft QBQ11 Arabic. These translators were citizens of English-speaking countries, whose parents were immigrants from Arabic-speaking countries and fluent in both Arabic and English.
Step IV: Expert committee review process
Both backward translations were sent to the developers of the OBQ for their feedback. Thereafter, a meeting was convened between the forward and back translators and the first author to discuss the feedback from the developers, and the OBQ11-A was formulated.
Stage 2: Field testing
The content validity of OBQ11-A was examined during the field testing. This type of validity refers to whether the instrument appears to measure the concept and covers all relevant domains and was typically evaluated by experts in the field (Streiner et al., 2015). The field testing was performed in two steps as described:
Feedback from occupational therapists
First, ten Arabic-speaking OTs provided feedback on the content and comprehension level of OBQ11-A. They were asked to rate the instrument using five statements adapted from Alnahal and May (2012): 1. The questions were clear and easy. 2. The questions covered all the aspects of OB. 3. You would like the use of this questionnaire for future assessments of OB, if needed. 4. The questionnaire lacks important questions regarding OB. 5. Some of the questions violate your privacy. The response options were as follows: strongly agree, agree, undecided, disagree, and strongly disagree (Alnahhal and May, 2012). The responders also had the opportunity to comment on these questions in an open-ended comments section.
Feedback from volunteers with various backgrounds
Second, the OBQ11-A was administered to seven volunteers with a variety of backgrounds during the field testing. These volunteers comprised two mothers of children with disabilities who were attending OT services, one rehabilitation coordinator, two speech therapists, one physical therapist, and one nursing assistant. Two of them were men and five of them were women. All of them were married and had children. The volunteers were interviewed by the first author using meaning-oriented, process-oriented, and sensitivity probes after they completed OBQ11-A (D’Ardenne, 2015). Comprehension probes refer to how well the participants understood the questions in OBQ11-A and interview questions such as “Can you explain the question in your own words?” were used to elicit responses. Judgment probes refer to how the participants arrived at the answer. For this, participants were probed with questions such as “You have chosen agree to this statement. Can you explain why you chose that option?” Sensitivity probes relate to whether the participants find the questions to be too much of a private nature, which was elicited through questions such as “Do you think the question asks about too much private information?” They also provided initial data for test–retest reliability by answering the OBQ11-A second time after 7–10 days.
Stage 3: Initial validation
Preliminary psychometric properties for the OBQ11-A including internal consistency, construct validity, and convergent validity were examined in the third stage of the study. Internal consistency refers to the degree to which individual items in the questionnaire measure the same concept (Streiner et al., 2015). Construct validity refers to the ability of the instrument to cover all aspects related to the construct. Examining the relationship between the scores obtained from questionnaires that measure concepts that are supposed to be related to each other is considered as a measure of convergent validity (Streiner et al., 2015). The relationship between OB as measured by OBQ11-A and Family Quality of Life as measured by FQOL-2006 was used in this study to examine convergent validity.
Demographic characteristics of Arabic participants.
Notes: PTDC: Parents of typically developing children; PCWD: parents of children with disabilities.
Data analysis
The content validity of OBQ11-A was assessed descriptively by inspecting the percentage of agreement among the ten OTs on the content validity questions followed by qualitative content analysis of the cognitive debriefing interview transcripts from the seven volunteers. The interviews were audio-recorded and transcribed verbatim for the analysis. Since the number of participants who provided test–retest data was very small (seven), the number of occasions where scores changed between test and retest was counted.
Cronbach’s alpha was calculated to examine internal consistency of the OBQ11-A, and value of more than 0.8 was considered good (Alnahhal and May, 2012). Factor analysis was used to test construct validity. Factor structure helps to determine the extent to which the structure of the measure is replicable in different populations and thus ensuring its generalizability (Meyers et al., 2017). In factor analysis, a coefficient of 0.40–0.45 range is considered as a minimal requirement for smaller samples, and factor loadings of 0.7 is considered excellent (Meyers et al., 2017). Spearman’s correlation coefficients were calculated to examine the association between OBQ11-A and FQOL-2006 with the aim of verifying convergent validity. A correlation coefficient of 0.5, 0.3, and 0.1 could be considered as large, moderate, and small, respectively (Meyers et al., 2017). According to Streiner et al. (2015), the level of the relationships should be neither too low nor too high because a low relationship means that there is a problem with the instrument and a high correlation could indicate that both instruments are measuring the same concept.
Results
Development of OBQ11-A
As previously described, the OBQ11-A was translated from the English version of OBQ11 in several steps, and written notes were made throughout this process. The comments mainly concerned the choice of words. For example, equivalent words in Arabic could not be found for just in “I feel there are just enough things to do” and really in “I make sure I do things I really want to do”. The stated words were thus omitted in the translated version as the Arabic questions still retained the same meaning as in the English version without these words. An equivalent word for drain as in “activities that drain my energy” could not be found in Arabic, and the word that means “exhaust” was used instead. In addition, an equivalent word for “leisure” was not found in Arabic and hence the word “al-tar-fe-heyya” in Arabic was used, which according to the translators, formally meant entertainment but encompasses leisure activities. Therefore, the word “entertainment” was used in the Arabic version for leisure in the statement “I balance the different kinds of activities in my life, for example, work, household chores, leisure, rest, and sleep”.
Results from field testing of OBQ11-A
Content validity was examined through the feedback from ten Arabic-speaking OTs and seven other volunteers from different backgrounds, during the field testing of OBQ11-A.
Feedback from occupational therapists
Content validity of OBQ11-A (n = 10).
Note: OBQ11: Occupational Balance Questionnaire.
Cognitive debriefing
The seven volunteers were questioned with comprehension, judgment, and sensitivity probes during the cognitive debriefing (D’Ardenne, 2015). The significant findings from the content analysis of cognitive interviews are summarized below.
Comprehension probes
All the participants stated that the items in the OBQ11-A were generally easy to understand. One participant mentioned that the word “physical” on item 6 was difficult to make sense of. Another participant felt that a few questions took time to complete. He stated, “not difficult but it took some time with some questions for me to think”. Items 6 and 7 were reported to be confusing by one participant. As the participant reflected on the question during the comprehension probe, she/he felt the need to change the response.
The examples that the participants provided were appropriate most of the time in those categories of occupation such as “things that I do for myself” and “things that I do for others.” Some peculiarities in the responses are described. Most participants struggled to provide specific examples for things that they did for themselves. When probed to give examples of activities they do for themselves, they used a literal translation, phrases like “activities that I do for myself,” “my enjoyment” rather than giving specific examples. One participant when describing an activity that she did for herself invariably related to activities that she did for her family such as shopping for family and helping children with homework.
According to one participant, an activity that usually generates energy for her could sometimes drain her energy when “not performed well.” In another instance, a same activity (caregiving occupation) was described as energy-giving by one participant while another participant described it as energy-consuming.
Judgment probes
Choosing the response options was easy for all items except for question seven, “satisfied with the amount of time I spend on my various daily activities,” which was reported to be confusing by two participants. This confusion arose as they felt they were satisfied with some activities but not with others.
While choosing the response options, most participants did not rely on recalling the actual time spent on activities during the week they were to assess OB. For example, one participant mentioned “I base that (balance) on satisfaction when I sleep and wake up and feel that I’ve slept well, that’s fine regardless of the time that I’ve slept”. When probed about the basis of balance another participant replied, “satisfaction and results so if I plan to do 1-10 and I’ve done them that means it’s a good week to some extent.” For yet another participant, balance concerned time and physical effort.
Sensitivity probes
All participants responded negatively for probes about whether the questionnaire asked for information that was deemed to be too private.
Preliminary test–retest data
The seven participants in Stage 2 completed the OBQ11-A twice. The responses differed between the test and the retest 14 times out of the total of 77 possible. No changes were reported for items 2 and 4 across all participants between test and retest. Changes in response were noted once for items 1, 3, 10, and 11 during retest and twice for items 5, 6, 7, 8, and 9.
Initial validation of OBQ11-A
Internal consistency
Internal consistency results for OBQ11-Arabic (n = 67).
Note: OBQ11: Occupational Balance Questionnaire.
Construct validity
Exploratory factor analysis
Factor loadings of Arabic OBQ11-A.
Note: OBQ11: Occupational Balance Questionnaire.
Convergent validity
Statistically significant positive correlation was found between total OBQ11-A scores and Global FQOL-2006 scores [rs = 0.552, n = 67, p < 0.001]. The Spearman correlation coefficient of 0.552 was considered a moderate association (Meyers et al., 2017), suggesting the convergent validity is in the acceptable range.
Discussion
The present study describes the process of translating the OBQ11 from English to Arabic to meet the need for measuring OB among Arabic-speaking people. The translation process followed the standard procedures reported in the literature (Beaton et al., 2000). The OBQ11-A was found to be easy to understand and to have good content validity, construct validity, convergent validity, and internal consistency.
Only minor modifications were made during the stages of the translation, which were similar to the translations of the OBQ from Swedish to English (Yu et al., 2018), to Norwegian (Uhrmann et al., 2019), and to Turkish (Günal et al., 2020). The content validity feedback from Arabic-speaking OTs supports the indication that the concepts from the English version are well reflected in the Arabic version. The unanimity of responses about the comprehension level suggests that the OBQ11-A was generally easily understandable, despite the low number of participants for cognitive debriefing. It was only for item seven, relating to satisfaction with the amount of time spent on various daily activities, where a little ambiguity was found. No modifications were made as alterations would change the meaning implied in the original questionnaire. Based on the observations from the cognitive debriefing, participants often talked of things they did for their family as things they did for themselves. This could be related to the collectivistic tendencies found in the Arabic culture (Buda and Elsayed-Elkhouly, 1998). This insight regarding the larger role of family in this culture needs to be confirmed in further research.
The OBQ11-A showed good internal consistency. The factor loadings for item 1, about having enough things to do, was low compared to the other items. This was similar to the findings by Uhrmann et al. (2019) in the Norwegian sample, where it was suggested that their findings could be related to the great majority of the participants in their sample being employed (91.2%). Although the percentage of employed in the current study was still high (almost 71%), it could be assumed that item 1 does not appear to contribute more in terms of measuring OB. The moderate relationship between OBQ11-A scores and FQOL-2006 global scores indicates good convergent validity. This finding is significant, and it adds evidence to the role of OB in quality of life (Park et al., 2020; Wagman et al., 2019).
Implications
The OBQ11-A developed in this study has provided the opportunity for assessing OB among Arabic-speaking clients in OT. However, studies examining further psychometric properties are required before it can be used in routine clinical practice for measuring changes in OB in response to interventions. The availability of an Arabic version can stimulate further research on OB in the Arab world, which is less represented in research concerning OB.
Limitations
During the translation process, it was found that an equivalent word for leisure did not exist in the Arabic language and hence a word that implies entertainment was used in the translation. This could be a potential limitation because the word used in the Arabic version might not capture the range of activities described as leisure in English. Qualitative studies on leisure in Arabic participants would help to explore how leisure is perceived and expressed in Arabic culture.
Content validity for OBQ11-A was derived from ten occupational therapists and seven volunteers. Replication of this study, particularly cognitive debriefing, is required with larger samples across diverse population groups.
Although indications for test–retest reliability were derived from six participants, statistical analyses could not be performed due to the extremely small sample. Future studies are recommended to examine test–retest reliability of OBQ11-A.
The study was, however, conducted in accordance with standard guidelines for translations, and the procedure is described in detail. The current work is only a starting point for further validation of the OBQ11-A.
Conclusion
Preliminary findings from the current study support the psychometric properties of OBQ11-A in terms of content validity, construct validity, convergent validity, and internal consistency comparable to other language versions.
Key findings
• OBQ11-A is easily understandable by Arabic-speaking participants and had good validity.
What the study has added
The study has resulted in the development of an Arabic version of OBQ11, thereby creating opportunities for occupational therapists to use it in clinical practice and research among Arabic populations.
Footnotes
Acknowledgements
We would like to thank Mr. Sultan Salim Hammam Al Abdulla, Chief of Occupational Therapy and Mr. Alvin Rol Carpio, Pediatric Occupational Therapy Supervisor of Hamad Medical Corporation.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Hamad Medical Corporation (grant no. MRC-01-18-465).
