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1. Introduction

hrough participation in everyday occupations, people experience and master various skills, communicate with others, and find purpose and meaning of life [1]. Engagement in meaningful occupations, which result in the well-being of people and their communities, is of importance. It is one of the human rights and it should be assured by equitable access to participation, regardless of differences [2]. The central focus of occupational therapy is promoting the health and well-being of people through occupation. Occupational therapy focuses on enabling people to participate in everyday occupations that are meaningful to them, giving them a sense of satisfaction, and leading them to their involvement in everyday life [3]. Enhancing participation in occupations is the key point.

The “Occupational Therapy Practice Framework: Domain and Process”, an authorized essay of the American Occupational Therapy Association, provides a comprehensive view of different aspects of participation. According to the “Framework”, participation in occupations consists of the following 8 life domains: social participation, work, education, Instrumental Activities Of Daily Living (IADLs), Activities Of Daily Living (ADLs), rest and sleep, leisure, and play [1].

Studies have shown that participation in various occupational areas has a significant role in the development of skills and health promotion [4-8]. On the other hand, the lack of participation or deprivation of meaningful and purposeful activities leads to a reduction in health and wellness [9].

Maintaining a satisfactory balance between these occupational areas, despite having a disability, is a determinant of health and well-being. One of the main goals of occupational therapy is achieving and sustaining occupational balance [10]. Accordingly, in occupational therapy, the accurate evaluation of daily occupations, in which people participate, is essential.

Concepts such as occupation are understood differently in various cultures. Besides, cultural expectations in disparate social contexts affect the type of activities that people do and the way they learn or perform them. For instance, research has shown that culture can have a significant influence on the level of participation in occupational areas. Thus, there are great differences among countries on this issue [11].

In recent years, many measures have developed to evaluate participation. The majority of participation measures have developed in foreign countries and often in the English language [12-14]. As a result, researchers interested in exploring this construct in a different language have had 2 options either to develop a new measure or to translate and use an existing one.

The aim of this study was to review all accessible resources thoroughly to collect and criticize the available assessment tools in Persian, which assess participation in at least one occupational area. This would be helpful for Persian-speaking occupational therapists in selecting an appropriate measure for assessing different aspects of the occupation.

2. Methods

Eight bibliographic databases, including 4 Iranian (IranDoc, Medlib, Magiran, and SID) and 4 international (Cochran, PubMed, Scopus, and ScienceDirect) databases were searched. The time of publication was limited from January 1, 1990, until the end of October 2018. Multiple combinations of keywords (with appropriate truncation) related to the construct (e,g., participation) and measure (e,g., Persian, questionnaire, and reliability) were used.

Table 1 presents two examples of how the articles were searched in Iranian and international databases. Search strategies in other databases are available from the authors on request.

Two researchers reviewed the title and abstracts independently. They assessed both generic and condition-specific measures that met the subsequent criteria: 1. they had been developed or validated for use with Persian-speaking people; 2. they seemed to cover items that assessed at least one domain of the “Framework”; 3. they existed in Persian; 4. there was information available on their psychometric properties; 5. their full text was accessible. At the next phase, full texts were looked over. References cited in retrieved articles were also searched and screened. Any disagreements during the selection processes were resolved in consultation with the third researcher.

3. Results

Figure 1 shows the procedure of searching databases, assortment, and the number of papers saved in each phase. Through 3 refining steps, 68 articles out of 3284 records were related to the present study.

Table 2 lists 50 extracted measures. A total of 44 of the scales were translated into Persian and 6 were established for the Iranian population. The number of items in the included measures ranged from 5-197.

Table 3 presents the psychometric properties of the assessment measures and the “Framework” dimensions that they cover (Most studies reported on the validation of measures). Different types of validity (content, construct, criteria, convergent, and divergent validity) and reliability (inter- and intra-rater and internal consistency) were assessed for measures. Most of the measures assess just one occupational area and 14 evaluate 2 or more.

4. Discussion

In comparison to the majority of systematic reviews, which emphasize the psychometric properties of measures, the present study analyzed the content of the measures. This helped to recognize the strength and limitations of these measures, as well as the development of a more efficient measure. It also provided a source of available participation measures in Persian for clinicians and researchers.

This study revealed that out of 50 measures, which evaluate the different aspects of participation available in Persian, only the following 6 measures have developed based on Iranian culture and have acceptable psychometric properties: “Iranian Children’s Participation Assessment Scale”, “Iranian Male Adolescents Outcome Expectation about Leisure Time Physical Activity”, “Self-regulation about Leisure time Physical Activity”, “Self-efficacy about Leisure Time Physical Activity”, “Work-related Low Back Pain Predictor Questionnaire”, and “Social Participation Questionnaire” (Table 3).

The rest were developed in other countries and translated to Persian. It is essential to consider cultural differences when using any assessment developed in another country. Although international standards for translating some measures (e,g., “Sleep Hygiene Index” and “Occupational Gaps Questionnaire”) have been respected and cultural differences have been investigated, in many cases, such as “Children Assessment of Participation and Environment” and “Assessment of Life Habits”, it is weakly considered.

It is recommended to Iranian therapists to develop or revise existing assessments to more fully measure the problems and needs of Iranians. Assessments should measure occupational participation and occupational performance based on the culture, in which the assessment is used. Borrowing assessments from another country, culture, or profession always result in some limitations of effectiveness and efficiency. Concepts can be borrowed, but they must be interpreted concerning the people’s culture being assessed. As a result, assessing cross-cultural validation for translated measures is suggested.

The “Occupational Therapy Practice Framework: Domain and Process” provides a comprehensive view of occupational areas. Considering the importance of accurate and inclusive assessment of this construct, it was decided to use the last version (third edition) as a framework for reviewing the available participation measures in Persian. Measures that contained at least once about each of the “Framework” domains, were identified. As presented in Table 2, only the Iranian children’s participation assessment scale, which developed based on the “Framework”, covers all domains of participation.

Ignoring the aspects of occupations may limit the measure usefulness as a measure of individuals’ reported participation. Therapists should consider the occupational areas in selecting an appropriate assessment tool. Therefore, it is suggested that although it is costly and time-consuming, researchers develop assessment tools that thoroughly cover occupational areas based on our culture in different populations.

As the “Framework” was created for the practice of occupational therapy in the United States, any use of the document outside the United States must acknowledge that the document does not account for other cultures or cultural differences. It is recommended that Iranian therapists write a document based on the “Framework” considering Iranian values and beliefs regarding participation in occupation in Iranian society and best approaches to assessment and intervention as applicable in rehabilitation programs in Iran.

It is highly important to consider psychometric properties (validity and reliability) of the measure while selecting the most appropriate one to evaluate efficacy and change over time. Almost all measures were evaluated in terms of some forms of reliability (e.g., internal consistency, inter- and intra-rater reliability) or validity (e.g., content, construct, convergent, and divergent validity).

Most of the measures offered only a Cronbach’s alpha, which provides information on how well items within a measures group together (e,g., Insomnia Severity Index, Iranian Male Adolescent’s Outcome Expectation about Leisure Time Physical Activity, and Independency Scale of Activities of Daily Living in Table 3). Problematically, Cronbach’s alpha does not provide evidence of repeatability. There are several approaches to estimate reliability, such as test-retest and inter-rater reliability, which provide this type of evidence. This information needs more investment in data collection, but it is worthy to assess these types of reliability.

In the same way, most validity evidence came from the study of content validity. Structural validity (the degree, to which scores of a questionnaire are an adequate reflection of the dimensionality of the construct to be measured) and criterion validity (the degree, to which the scores of a health-related patient-reported outcomes measure are an adequate reflection of a “gold standard”) require greater sampling to administer the measure in multiple groups or to collect a gold standard measure [75]. Few studies have investigated the former type of validity (e.g., community integration questionnaire, Craig hospital inventory of environmental factors, and Epworth sleepiness scale in Table 3). Multiple strategies should be included for a comprehensive assessment of the psychometric properties of a measure. These require researchers to allocate more time to measure development by gathering data across multiple time points, in multiple samples, or along with a gold standard.

Additionally, it is highly important to note that the quality of a measure and methodological quality of the study, which assessed the psychometric properties of the measure, are two different issues. If the methodological quality of the study is inadequate, the results cannot be trusted and the quality of the measure under study remains unclear. Terwee et al. developed criteria for good measurement properties that can guide occupational therapists in assessing the quality of the measure [76]. On the other hand, in recent times, an international Delphi study was done to develop the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist for evaluating the methodological excellence of studies on measurement properties.

The COSMIN taxonomy and checklist can help the researchers to identify the need for further research on measurement properties. Researchers can also use the COSMIN checklist in designing their study to make sure that it meets the standards for excellent quality [75, 77].

Another important consideration when selecting a measure is its application for the target population. Measures developed for one setting or a special health condition should only be generalized with caution. The reliability and validity of most of the measures included in this review were assessed in certain populations, where their applicability in other groups remains questionable and needs more investigation. Limited access to the full text of some articles was a limitation of the present study. Because of the high number of measures identified, it was impossible to assess all of them based on the COSMIN checklist. It is, therefore, recommended to conduct future studies on assessing the measures based on the COSMIN checklist.

Implications to practice, research, and education

This study by reviewing general characteristics (e,g., content, number of items, time, and format of administration) and psychometric properties of Persian participation measures in different occupational areas will help Persian-speaking therapists to select appropriate measures for assessing participation in occupational areas based on their resources.

Since the comprehensive assessment of occupational areas is crucial for enabling people in achieving occupational balance, clinicians and researchers can use the framework as a guide in selecting or developing measures. Also, measuring occupation from a culturally sensitive perspective is particularly important.

It also helps Persian-speaking researchers identify the weakness of existing measures and guide them in improving them or designing new ones. It is recommended that researchers can use the COSMIN checklist as a tool for this purpose. The COSMIN checklist helps researches to: 1. identify which measurement properties are relevant for evaluating health-related patient-reported outcomes; 2. introduce terminology and definitions of these measurement properties; and 3. identify the design requirements and preferred statistical methods. Accordingly, adding the COSMIN taxonomy and checklist and measurement properties criteria proposed by Terwee et al. in assessment and evaluation courses can highly improve rehabilitation education and assessment processes.

4. Conclusion

Most of the available measures were developed in other countries and translated into Persian. Only a few developed measures based on Iranian culture included all participation in occupational domains. Since the comprehensive assessment of occupational areas from a cultural perspective is crucial for enabling people in achieving occupational balance, this critical review will help Persian-speaking therapists to select appropriate measures for assessing participation in different occupational areas. Considering the lack of comprehensive measures for assessing participation in different ages, developing measures based on cultural properties seems necessary.

Ethical Considerations

Compliance with ethical guidelines

The systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

Funding

The research has not received any funding.

Authors' contributions

Data acquisition: Ghodsiyeh Joveini; Reviewing and revising the manuscript critically: Mitra Khalafbeigi; Critical analysis and Data analysis: Ghodsiyeh Joveini, Laleh Lajevardi, and Armin Zareiyan; Developing the concept, Reviewing extracted articles, Extracting the measures: Ghodsiyeh Joveini, Laleh Lajevardi.

Conflict of interest

The authors declared no conflict of interest.

Acknowledgments

We would like to express our gratitude to Dr. Afsoon Hassani Mehraban, Ph.D of Occupational Therapy, Iran University of Medical Sciences, for sharing her knowledge in this research.

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