Occupational balance is a deceptively simple concept with deep roots in occupational therapy, the health profession concerned with helping people engage in the everyday activities, or occupations, that give life structure and meaning. Swedish researchers Petra Wagman and Carita Håkansson, both co-authors of the new study, defined it in earlier work as an individual’s perception of having the right amount of occupations and the right variation between them. Crucially, the definition is subjective: there is no universal formula dictating how time should be divided among self-care, work, leisure, and sleep. What matters is whether each person feels their mix of activities is sufficient and varied enough. Occupational imbalance arises when someone feels they are doing too little, too much, or lacking variety, and research consistently links this perception to well-being, quality of life, and mental health.

People with depression face particular obstacles in achieving this balance. Symptoms such as low mood, lack of interest and energy, and difficulties with decision-making, concentration, and memory reduce the capacity to perform personal care, household tasks, and social or productive activities. Many individuals scale back the roles they take on, withdrawing from chores, employment, and family responsibilities. Over time, depression can shift daily patterns toward sleeping and resting at the expense of active pursuits, further narrowing the variety of occupations. Prior research suggests that people with depression achieve occupational balance when they feel they have varied things to do, the right amount to do, satisfaction with how their time is spent, and a good mix of energizing and draining activities. Measuring where a patient stands on this spectrum is therefore essential for designing effective, individualized interventions, which is precisely why a validated assessment tool matters.

The instrument at the heart of the new study is the OBQ11, an eleven-item self-report questionnaire developed in Sweden and refined through Rasch analysis, a modern psychometric technique. Respondents rate each statement, such as having just enough to do during a regular week or balancing obligatory and voluntary occupations, on a four-point Likert scale from completely disagree to completely agree, yielding total scores from 0 to 33, with higher scores indicating better occupational balance. The questionnaire takes less than fifteen minutes to complete, making it practical for clinical use. It has already been translated into Spanish, Norwegian, Turkish, Arabic, Persian, and Danish, but until now no version existed for Chinese-speaking populations, and no tool had been found suitable for people in Taiwan.

Translating a psychological questionnaire is far more demanding than swapping words between languages, and the Taiwanese team followed a rigorous, standardized procedure. Two bilingual occupational therapists produced a forward translation into traditional Chinese, while a bilingual translator supported by a professional English editor handled the back translation. The first author then reconciled the two versions and corresponded directly with the OBQ11 developers to confirm accuracy. Some items proved stubborn: two required back translation twice, and one needed four rounds before the meaning aligned with the original. This iterative process, repeated across multiple reviews, ensured that each translated item preserved the intent of the Swedish source rather than merely its surface wording.

Cultural nuance surfaced most vividly in the expert review phase. Ten occupational therapy experts from across Taiwan, with an average of thirteen years of clinical experience, initially rated the translated items below the accepted thresholds for content validity, flagging ambiguous wording, difficult phrasing, and a missing instruction about the recall period. In response, the team refined item 1, clarifying that just enough things means an appropriate amount of activity, neither too little nor too much, and adjusted item 3 to indicate that it concerns doing some of the things a person genuinely wants. Item 9, which addresses balancing obligatory and voluntary occupations, required extensive discussion because the distinction itself is culturally loaded. The researchers noted that in Sweden people commonly separate activities they want to do, such as leisure, from activities they must do, such as work and caregiving, whereas in Taiwan obligations may align with personal desires and thus bring satisfaction. Parenthetical explanations of responsibility and voluntary were added, and after revision the expert-level content validity indices reached acceptable values, with item-level scores between 0.8 and 1.0 and a scale-level average of 0.93.

The validation then moved to the people who would actually use the questionnaire. Ten participants with depressive disorder completed cognitive debriefing interviews, confirming that they understood the items, and a larger sample of 161 adults with depressive disorder, recruited from two psychiatric outpatient clinics in central Taiwan, completed the finalized OBQ11-C. Participants averaged 39.2 years of age, were predominantly female, and had developed psychiatric disorders at an average age of 31.2 years. Of these, 131 returned a second completed questionnaire by mail within seven to fourteen days, allowing the team to assess stability over time. The results were striking: the intraclass correlation coefficient, a measure of test-retest reliability, reached 0.94, indicating excellent agreement between the two administrations, while Cronbach’s alpha, a gauge of internal consistency, stood at 0.90, and corrected item-total correlations ranged from 0.49 to 0.77, all comfortably above accepted standards.

Beyond classical test theory, the researchers applied Rasch analysis, a mathematical framework that converts person ability and item difficulty into a common unit called the logit and tests whether a questionnaire measures a single underlying construct. The analysis supported the four-point rating scale, confirmed that all items fit the model, and demonstrated unidimensionality, meaning the eleven items all tap the same construct of occupational balance. Item separation was 3.95 with item reliability of 0.94, and person separation was 2.87 with person reliability of 0.89, indicating the scale distinguishes both item difficulty levels and individual differences effectively. Principal component analysis of residuals explained 53.6 percent of the variance, and no floor or ceiling effects emerged, meaning the scale works across the full range of occupational balance levels.

Perhaps the most intriguing findings came from comparing item difficulty rankings across the Chinese, Swedish, Norwegian, and Danish versions. Some patterns held everywhere: item 3, concerning time for doing things one wants, consistently ranked among the easiest, while item 10, balancing energy-giving and energy-taking activities, and item 7, satisfaction with how time is spent, ranked among the hardest. But other items shifted dramatically between versions, by more than three ranking positions. In the Chinese version, the hardest item concerned balancing physical, social, mental, and restful occupations, plausibly reflecting the daily struggles of people with depression in managing chores, social interaction, and self-care. In the original Swedish version, balancing work, home, family, leisure, rest, and sleep posed the greatest difficulty, while Norwegian students found obligatory versus voluntary balance hardest, and Danish workers struggled with having sufficient time for obligatory tasks. These differences underscore that occupational balance is a personal, culturally situated perception shaped by age, health status, and life context.

The study has limitations the authors acknowledge: participants were adults aged 20 to 66 recruited from outpatient clinics in central Taiwan with relatively homogeneous characteristics, and properties such as criterion validity, differential item functioning, and minimal clinically important difference remain to be examined. Even so, the OBQ11-C now stands as the first validated tool of its kind for Chinese-speaking individuals with depression in Taiwan, giving clinicians a foundation for building individualized, occupation-based assessment and intervention programs. For a condition that affects one in twenty adults worldwide and reshapes the texture of everyday life, the ability to measure something as intimate as whether one’s days feel balanced, varied, and sufficient is a quiet but meaningful advance, one that may help therapists meet patients where they actually live.

Subject of Research: Validation of the Chinese version of the Occupational Balance Questionnaire 11 for assessing occupational balance in people with depression

Article Title: Psychometric properties of the Occupational Balance Questionnaire 11-Chinese version

Article References: Chen, Y.-L., Su, P.-C., Ko, W.-T., Hsieh, M.-H., Ju, P.-C., Chan, Y.-T., Wagman, P., & Håkansson, C. (2025). Psychometric properties of the Occupational Balance Questionnaire 11-Chinese version. Scandinavian Journal of Occupational Therapy, 32(1), Article 2559893. https://doi.org/10.1080/11038128.2025.2559893

Image Credits: AI Generated

DOI: 10.1080/11038128.2025.2559893

Keywords: occupational balance, Occupational Balance Questionnaire, depression, psychometrics, Rasch analysis, reliability, validity, occupational therapy, Taiwan, questionnaire translation, mental health, content validity