The origins of these methods stretch back to the 1960s, when anthropologists and ethnographers began incorporating photographs and film into their data collection. But the technique that has become most closely associated with participatory health research is photovoice, developed in the 1990s through studies in which rural Chinese women in Yunnan Province photographed scenes they considered representative of their daily lives. The method’s signature analytical tool, the SHOWED question sequence, asks participants what they see in an image, what is really happening, how it relates to their lives, why the situation exists, and what can be done about it. The explicit goal was social change: giving marginalized groups the means to communicate their experiences on their own terms and push for policy reform. That collaborative DNA, the review’s authors note, is precisely what makes visual methods attractive to occupational scientists, whose research agendas increasingly emphasize community engagement and societal responsiveness.

To build their evidence base, the researchers followed the six-stage scoping review framework developed by Arksey and O’Malley and extended by Levac and colleagues, in accordance with Joanna Briggs Institute methodology. They searched PubMed, Web of Science and CINAHL Ultimate in December 2023, with a follow-up search in December 2024, and registered their protocol with the Open Science Framework to increase transparency. The initial search yielded 3,619 references, which were reduced to 2,066 after deduplication in the Rayyan platform. Blind screening by two authors per citation, with a third author resolving disagreements, narrowed the field to 140 articles for full-text review and ultimately 59 included studies. Consultations with three international experts and the follow-up search added 14 more papers, producing a final sample of 73 studies from 68 first-named authors, all published in English between 2001 and 2024. Notably, 79 percent of the included studies appeared in just the last ten years, signaling a rapid acceleration of interest.

The geographical footprint of the evidence is strikingly broad. Europe and North America each contributed 25 studies, accounting for 34 percent of the sample apiece, with Ireland, the United Kingdom, Sweden, the United States and Canada leading the way. Australia and New Zealand produced eight studies, Africa seven, and South America and Asia three each. The authors observed that visual methods gained traction at different times in different regions, with later uptake in Asia, Europe and South America compared with North America, Australia and Africa. They attribute this pattern to differences in academic traditions, technological resources, cultural alignment with participatory approaches, and the influence of methodological innovations emerging from leading research groups. Intriguingly, studies are also increasingly appearing in journals outside occupational therapy and occupational science, including publications focused on rehabilitation, social sciences, education and qualitative methodology, a sign of expanding interdisciplinary reach.

The populations studied span every age group and health status. Children and adolescents featured in 26 papers, adults in 47, with and without disabilities or health conditions. Among adults, conditions recurring across multiple studies included mental health difficulties, cancer, stroke and terminal illness, alongside less common conditions such as spinal cord injury, diabetes, Addison’s disease, upper limb injuries and spina bifida. Some studies worked with dyads, exploring parents with disabilities, people with early onset dementia and their caregivers, and couples managing chronic conditions together. Among children with disabilities, eleven papers examined populations ranging from children with specific diagnoses to those with varied physical and developmental disabilities and even food allergies. The breadth suggests that visual methods are not confined to any single clinical niche but function as a genuinely general-purpose instrument for understanding occupation in context.

What were these researchers actually studying? Just over half of the papers, 37 in total, focused on specific occupations. Play topped the list with twelve studies, encompassing digital play, object play, risky play, playground use, and the play of infants and toddlers at home. Self-care and caregiving occupied seven studies, from caring for a dying relative to the pre-sleep routines of typical adults and the home-making practices of people experiencing homelessness. Seven papers examined occupations of dyads, groups or communities, including an older couple’s shared walks, the multispecies occupation of humans and horses, youth cycling groups, community gardening and partying. The remainder covered return to work after injury or cancer, tapestry weaving, religious practices, powered wheelchair use and computer use. Nineteen papers explored general experiences of daily life rather than a single occupation, fourteen examined concepts related to occupation such as quality of life, well-being and occupational identity, and three addressed occupational justice, including how gender and material poverty shape occupational choices.

Methodologically, photovoice dominated the toolkit, appearing in 23 studies, or 32 percent of the sample, followed by photo-elicitation in 19 papers, videography and video observation in 11, unstructured photography in 7, and drawing and collage techniques in 3. Ten studies combined multiple visual methods within a single design. In 31 studies the visual method was the primary and only data collection approach, typically paired with the semi-structured or focus group interviews that photovoice and photo-elicitation protocols prescribe. In 22 other studies, visual methods served as one component among several, combined with contextual observations, behavioral mapping and interviews. The authors illustrate this with studies of outdoor play among autistic preschoolers, where researchers deployed video recordings, participant photography, observation and caregiver interviews simultaneously, and of tapestry weaving in residential aged care, which layered photographs, video, field notes and interviews. Ethnography, used in 12 studies, and phenomenology, used in 11, were the most common overarching frameworks, and 93 percent of all included studies were qualitative.

How the visual material itself is analyzed emerged as one of the review’s most revealing findings. Thematic analysis, most often citing the influential framework of Braun and Clarke, was the dominant analytical approach, used in 27 papers, or 37 percent, applied to both textual and visual data. Phenomenological analysis appeared in eight papers, and six followed the photovoice analysis process described by Wang and Burris. Yet the review uncovered a methodological soft spot: in 16 studies the visuals served only to stimulate discussion and were not themselves analyzed, and in 12 studies the authors made no explicit mention of analyzing the visual materials at all. Only 31 percent of the papers discussed ethical considerations specific to collecting, analyzing and publishing visual data, a striking gap given that photographs and videos can expose identities, homes and intimate moments in ways that interview transcripts cannot. Eight studies did share findings publicly through photograph exhibitions, participant-produced booklets and websites, hinting at the participatory promise the methods hold.

The review’s implications are clear-eyed about both promise and peril. Visual methods, the authors argue, are not merely novel gimmicks but powerful instruments that capture the complexity, context and lived texture of occupation in ways traditional verbal methods often miss. They can open the door to participants who communicate more comfortably through images than words, and they are naturally suited to community-based participatory research. But the field needs rigor: researchers should articulate a clear purpose for using visual methods, follow or transparently adapt established protocols, document the practical details of data collection such as device type, time frame and participant instructions, and explain whenever visuals are excluded from analysis or publication. The authors also flag emerging frontiers, including occupational mapping, digital storytelling, participatory video and the study of multispecies occupations involving animals as active partners rather than passive props. As the discipline matures, the challenge will be to match the creativity of the camera with an equally disciplined methodology, ensuring that what researchers see through the lens translates into knowledge that is rigorous, ethical and genuinely useful for the people whose lives it depicts.

Subject of Research: The use of visual research methods such as photovoice and photo-elicitation in occupational science and occupational therapy research

Article Title: Using visual research methods to study occupations: A scoping review

Article References: Bratun, U., Morgenthaler, T., & Lee, B. D. (2025). Using visual research methods to study occupations: A scoping review. Scandinavian Journal of Occupational Therapy, 32(1), Article 2519261. https://doi.org/10.1080/11038128.2025.2519261

Image Credits: AI Generated

DOI: 10.1080/11038128.2025.2519261

Keywords: visual research methods, photovoice, photo-elicitation, occupational science, occupational therapy, scoping review, qualitative research, videography, participatory research, thematic analysis, human occupation, community-based research

The immediate trigger for the editorial is a cluster of recent US regulatory developments, most prominently Executive Order 14279, titled ‘Reforming Accreditation to Strengthen Higher Education,’ published in the Federal Register in April 2025. The editors read this order, alongside related regulations that could restrict diversity, equity, and inclusion initiatives, as imposing constraints that may undermine three pillars they identify as foundational to academic life: the freedom to learn and teach, the freedom to conduct and valorize research, and the freedom to communicate scientific results both within and beyond academia. Their concern is not abstract. They cite reporting of anger and despair from within the US federal research system, including accounts of scientists who feel compelled to publish their work anonymously out of fear of potential repercussions, a practice that strikes at the heart of scientific accountability and attribution.

The first pillar the editors examine is the freedom to learn and teach. Academic freedom, they argue, is the cornerstone of a vibrant educational environment and is profoundly connected to societal development and human well-being. It guarantees that educators and students can engage in open dialogue, explore diverse perspectives, and challenge prevailing norms without fear of retribution. In their assessment, the recent US regulations prioritize certain ideological standards over educational quality and significance, threatening to stifle intellectual diversity and critical thinking. The technical consequence, they suggest, is a narrowing of the epistemic range within classrooms and curricula: when accreditation frameworks reward conformity to prescribed positions rather than intellectual rigor, the educational experience itself degrades, knowledge development slows, and universities lose their function as spaces for free and open inquiry. For a discipline like occupational therapy, whose practitioners must reason across biological, psychological, social, and cultural domains, that narrowing is not a peripheral concern but a direct threat to professional competence.

The second pillar concerns the freedom to conduct research and to translate its results into value for society. The editors emphasize that the ability to pursue inquiries wherever the evidence leads, without undue interference, is essential for scientific progress. Research on health, disability, aging, and social participation, the core territory of occupational science, depends on the willingness of investigators to follow data into politically sensitive terrain, whether that involves inequities in access to care, the lived experience of marginalized groups, or the evaluation of policies that affect daily functioning. Regulations that could restrict diversity, equity, and inclusion initiatives may, in the editors’ view, pose a direct threat to this freedom by limiting both the scope of permissible research questions and the dissemination of findings. The downstream effect is a slower and less reliable pipeline from discovery to application, hindering the advancement of knowledge and its use in addressing societal challenges and improving people’s health.

The third pillar, communication, receives perhaps the most pointed treatment. The editors describe the freedom to communicate scientific results as vital for the dissemination of knowledge, for democracy, and for the overall advancement of society. Researchers must be able to share findings with both the academic community and the public. Recent US policies, they warn, could create an environment of fear and self-censorship in which researchers become reluctant to publish controversial or politically sensitive results. The mechanics of this loss are worth spelling out: science advances through the open circulation of results, methods, and replications, and public policy depends on access to the best available evidence. When scholars withhold findings, bury inconvenient data, or anonymize their authorship to avoid retaliation, the scholarly record becomes incomplete and unattributable, peer review loses leverage, and the public is deprived of information that can inform policy and improve lives. The editors characterize this as a significant loss of valuable scientific contributions that would affect everyone, not only the academic community.

Underpinning the entire editorial is a normative claim about the legal and moral status of academic freedom. The editors assert that academic freedom is a key right, an inherent part of the human right to education, as recognized by the United Nations and by the European University Association. They point to the UN’s 2025 report on academic freedom and the freedom of opinion and expression, issued by the Office of the High Commissioner for Human Rights, and to a further UN document, the report of the Special Rapporteur on the right to education on the right to academic freedom, which together articulate a framework in which academic freedom encompasses the freedom to access, disseminate, and produce information, to think freely, and to engage with a diversity of knowledge. The European University Association has similarly published guidance on how universities can protect and promote these freedoms. Within this framework, the editors argue, the recent actions of the US administration could threaten fundamental freedoms and pose a significant risk to the integrity and progress of higher education and research.

The editorial is also notable for its institutional provenance. Its lead author, Anita Björklund Carlstedt, is Editor-in-Chief of the Scandinavian Journal of Occupational Therapy, based at Jönköping University in Sweden, and the co-authors include national editors affiliated with VIA University College in Denmark, Gothenburg University, Umeå University, and Oslo Metropolitan University, alongside the presidents of the Swedish, Danish, Finnish, Icelandic, and Norwegian associations of occupational therapists, several of whom serve on the board of the journal’s foundation. This breadth matters because it signals that concern about academic freedom is not confined to political scientists or legal scholars but extends to applied health disciplines whose practitioners work daily with people whose well-being depends on evidence-informed services. The journal’s leadership explicitly positions itself as part of the global research community, using its editorial platform to amplify what it describes as unprecedented challenges facing peers in the United States.

The editors are candid about the immediate consequences for their own fields. As professionals in occupational therapy and occupational science, they write, they are acutely aware of the effects these actions have on their disciplines, from disrupted collaborations to constrained research agendas. But they insist the implications extend far beyond occupational therapy, affecting the entire research community and undermining the trustworthiness of science and evidence itself. Their argument here is essentially one about epistemic infrastructure: modern evidence-based practice, whether in healthcare, education, or public policy, is built on the assumption that research is conducted and reported without ideological filtering. Once that assumption weakens, the credibility of every downstream product, from clinical guidelines to systematic reviews to public health recommendations, is called into question. The editors argue that scientists carry a responsibility to uphold these principles and to ensure that their work remains credible and impactful for societal growth, a responsibility they frame as inseparable from the scientific role itself.

The editorial closes with a call to action rather than a resignation. The authors urge the global academic community to defend and advocate for worldwide academic freedom and to stand in solidarity with colleagues in the United States. What solidarity looks like in practice is left to readers to determine, but the editorial itself models several possibilities: journals can use their editorial pages to document threats to scholarship, professional societies can lend their institutional weight to cross-border statements, and researchers in less affected countries can publish, cite, and collaborate in ways that keep threatened lines of inquiry alive. The piece, published on 23 June 2025 and available open access under a Creative Commons license, is short, spanning just two pages, but its reach is deliberately global. By framing academic freedom as a human right and its erosion as a shared professional emergency, the Scandinavian editors have turned a regional journal’s editorial into a signal flare for researchers everywhere who believe that science cannot function under conditions of fear, censorship, or ideological control.

Subject of Research: Threats to academic freedom in US higher education and research and international solidarity with affected researchers

Article Title: Defending academic freedom and showing solidarity with US researchers

Article References: Björklund Carlstedt, A., Helle, T., Häggblom-Kronlöf, G., Nilsson, I., Sveen, U., Thordardottir, B., Kåhlin, I., Nør Langager, T., Wikman, K., Leosdottir, T., & Holst Skyer, T. (2025). Defending academic freedom and showing solidarity with US researchers. Scandinavian Journal of Occupational Therapy, 32(1), Article 2520102. https://doi.org/10.1080/11038128.2025.2520102

Image Credits: AI Generated

DOI: 10.1080/11038128.2025.2520102

Keywords: academic freedom, US higher education, Executive Order 14279, occupational therapy, occupational science, research ethics, science policy, self-censorship, human rights, Scandinavian Journal of Occupational Therapy, DEI restrictions, scientific communication

Occupational science, the field that studies how everyday activities shape human health and identity, has long been anchored in Western, autonomy-centered paradigms. Its foundational models emphasize volition, personal choice, and self-expression as the engines of occupational identity. But Budman and Bourke-Taylor point out that these assumptions may simply not hold in traditional, faith-based communities, where motherhood is not a lifestyle decision but a divinely ordained vocation. In such settings, maternal roles are socially prescribed, religiously defined, and structurally reinforced, meaning that the very concept of ‘choice’ operates differently than mainstream theory predicts.

To build their framework, the researchers used a reflective thematic synthesis of two previously conducted qualitative studies with ultra-Orthodox Jewish mothers—one using semi-structured in-depth interviews and the other using focus groups. Rather than re-coding raw transcripts, the team revisited original thematic matrices, analytic memos, and interpretive reflections to extract patterns with theoretical relevance. They then triangulated these empirical findings with three theoretical lenses: role theory, which explains how societies define and enforce roles like ‘good mother’; occupational identity theory, which describes how people come to know themselves through what they do; and occupational justice, which examines how structural barriers limit access to meaningful activity.

The result is a framework with five interrelated domains: Spiritual Meaning and Obligation, Communal Structures and Expectations, Family Dynamics and Resources, Health and Well-being Outcomes, and Negotiation and Adaptation. The first three act as foundational forces, embedding mothering in shared values, moral obligations, and systemic conditions. The final two capture how mothers respond over time—reprioritizing daily occupations, seeking guidance from religious authorities, or reframing struggles through a spiritual lens. Together, the domains model the interplay between structure and agency, showing identity as something continuously negotiated rather than fixed.

The ultra-Orthodox Jewish community in Israel provides a striking case study. Composed of Hasidic, Lithuanian, and Sephardic groups united by adherence to halacha, or Jewish law, the community structures daily life around spiritual practice. Because Torah study is prioritized—especially for men—women typically assume central responsibility for caregiving, household management, and often financial provision. Large families are common, and mothers are viewed not merely as caregivers but as transmitters of tradition and protectors of communal boundaries. Motherhood, in this context, is a sacred vocation shaped by teachings about self-sacrifice, modesty, and the sanctity of childrearing.

These conditions generate what the authors call deep occupational meaning alongside intense pressure. Communal structures—religious leadership, gendered education systems, and dense social networks—reinforce norms through what the researchers describe as social surveillance and communal cohesion. Maternal roles become publicly accountable as well as privately meaningful. For some mothers, this offers clarity, belonging, and identity affirmation; for others, it produces internal conflict when personal needs or aspirations diverge from communal expectations. Health and well-being, the framework suggests, are shaped not only by external demands but by internalized beliefs about what it means to be a ‘good’ mother, with well-being often measured by perceived success in meeting religious and familial expectations rather than personal fulfillment alone.

To illustrate the framework’s dynamics, the authors constructed two fictionalized composite vignettes based on common patterns in their data. The first portrays a 34-year-old mother of seven whose internal values and external environment are aligned: she keeps a kosher kitchen, orchestrates Sabbath preparations and holiday celebrations, and describes her home as a sacred space, finding coherence and satisfaction in roles her community affirms. The second portrays a 28-year-old mother of four who has begun part-time seminary studies and feels caught between communal expectations of prioritizing family and her desire for intellectual engagement and financial independence. Her story shows identity under tension—guilt over missed family meals, disrupted routines, and private questions about whether her aspirations are compatible with her faith.

The framework is also positioned as a critique and extension of two established occupational therapy models. The Model of Human Occupation, or MOHO, explains identity through volition, habituation, and performance capacity, but is grounded in individual agency—an emphasis that fits awkwardly where occupational roles are inherited and morally reinforced. The new framework situates volition within spiritual obedience and communal norms, suggesting that motivation is filtered through divine duty rather than emerging solely from personal preference. The Kawa Model, which uses the metaphor of a river shaped by rocks, banks, and driftwood to capture cultural context, offers narrative richness but does not explicitly theorize identity development. The proposed framework builds on both by showing how identity is actively constructed through alignment—or misalignment—between internal values and external expectations.

The authors are candid about the framework’s limitations. It is based on secondary analysis of previously published qualitative findings and reflects the researchers’ interpretations; it requires validation through participant feedback and application in other sociocultural settings. They also acknowledge an inherent tension: the foundational theories they build on originate from the very Western, autonomy-centered paradigms the framework critiques, and they describe engaging with these theories critically and reflexively. Future research, they argue, should explore how maternal occupational identity develops across the lifespan and in different religious traditions, with comparative studies clarifying which elements are context-specific and which have broader relevance.

Even so, the implications reach well beyond one community. For occupational therapists, the framework underscores cultural humility: clinicians working with mothers from traditional or minority communities must attend to the meanings, values, and expectations shaping maternal roles, or risk misinterpreting occupational needs and applying inappropriate service models. For occupational science, the work joins a growing critical movement calling for pluralistic, justice-oriented theory that accommodates collective meaning-making, spirituality, and diversity. The researchers suggest the framework may transfer to other collectivist or faith-oriented populations, including Indigenous, Muslim, and Christian communities where maternal identity is similarly shaped by collective values and gendered expectations. If validated, it could mark a meaningful step toward theories of occupation that recognize not just what people choose to do, but what they believe they are obligated to become.

Subject of Research: A conceptual framework for maternal occupational identity in faith-based minority communities

Article Title: Rituals, roles, and realities: A conceptual framework for maternal occupational identity in faith-based minority contexts

Article References: Rituals, roles, and realities: A conceptual framework for maternal occupational identity in faith-based minority contexts. (n.d.). https://doi.org/10.1080/11038128.2025.2558742

Image Credits: AI Generated

DOI: 10.1080/11038128.2025.2558742

Keywords: maternal occupational identity, occupational science, ultra-Orthodox Jewish mothers, faith-based communities, role theory, occupational justice, Model of Human Occupation, Kawa Model, occupational therapy, cultural responsiveness, motherhood, qualitative research

The scale of the problem is considerable. The Organization for Economic Co-operation and Development estimates that roughly forty million people across its 38 member countries are unemployed. Finland, a nation of 5.6 million, reported 311,100 unemployed individuals in August 2025, of whom 129,200 had been out of work for twelve months or longer, the threshold the International Labour Organization uses to define long-term unemployment. That gives Finland the second-highest unemployment rate in the European Union, and the number of unemployed people grew by more than 30,000 during the very period in which the study was conducted.

Despite this, occupational therapy research has largely ignored the situation. A 2018 search of a dedicated occupational therapy database found only ten articles with unemployment as their primary focus, and a repeat search for the present study added just five more. The authors, T. Turtiainen, L. Rosenberg and I. Jansson, note that most existing work concerns people returning to jobs they already have, or supporting those with disabilities into employment. People who have no job to return to have remained, in their words, somewhat neglected.

To fill the gap, the team adopted a phenomenographic approach, a qualitative method designed to map the different ways professionals understand and experience their own practice. Nine occupational therapists from three different regions of Finland and a range of organisational settings took part. Data were gathered through one focus group, two dyadic interviews and two individual interviews, with each participant or group meeting twice during April and May 2024 in sessions lasting 60 to 90 minutes. Analysis followed the established seven-step phenomenographic procedure of familiarisation, condensation, comparison, grouping, articulating, labelling and contrasting, with translation into English occurring only at the articulation stage to preserve original meaning. Participants were given the chance to comment on preliminary results, and all who responded approved them.

The analysis produced six categories of description, organised into two sets of three. The first trio captures how therapists currently work with unemployed people: Assessing, Coaching and Collaborating. The second captures how they believe the work should develop: Adapting to new ways of working, Increasing awareness of occupational therapy, and Advocating for better opportunities to participate in working life. Assessment emerged as the dominant activity. All participants assessed work ability and occupational functioning, and most described it as their main task, typically across one to seven meetings using interviews, standardised tests, self-assessments, observation and questionnaires.

Yet the assessment process itself revealed a structural paradox. Because unemployed clients have no workplace, therapists had nowhere to observe work-related performance directly, so evaluations were usually carried out in clinical settings, sometimes supplemented by visits to rehabilitative work placements. More strikingly, the therapists reported that assessments were frequently commissioned not to move clients toward rehabilitation or employment, but to determine eligibility for benefits, disability pensions or assistive devices, often because a physician’s medical statement was too thin to satisfy the authorities. One participant described seeing rejected statements and immediately understanding why: they simply lacked adequate descriptions of work ability, meaning the entire assessment had to be redone.

Coaching, by contrast, was a goal-oriented practice aimed at enhancing work ability at a pace suited to each individual, whether by practising job interviews, building social skills, establishing daily rhythms or finding training placements. Some therapists used the Individual Placement and Support model and worked directly with employers, intervening early whenever a job was at risk. But coaching also exposed how alien the world of work had become for many clients. Some had never worked or had been away from employment for years, and therapists described clients who were strikingly unaware of their own rights, responsibilities and opportunities within the unemployment and social insurance systems. As one participant put it, the role of worker is one of the roles of adulthood, yet healthcare services often speak only of inability, never of what work could mean.

Collaboration was described as essential but chronically underdeveloped. Therapists contributed expertise on work ability and human occupation to multiprofessional and multisectoral networks spanning health, social and employment services, yet many reported being invited only occasionally, or forgotten altogether when meetings were arranged. Participants described services as fragmented, with professionals rarely talking to one another and clients often unaware of who was even part of their own support network. One participant called collaboration the most important part of occupational therapy practice with unemployed people, while another summed up the consensus bluntly: no one knows these things alone. With only about seven occupational therapists per 10,000 inhabitants in Finland, the profession’s low visibility outside healthcare compounds the problem.

The deeper tension the study uncovers is a conflict of roles. Therapists want to be advocates, pushing for earlier interventions, employment services that employ occupational therapists directly, and more humane labour markets that see people’s capacities rather than their diagnoses. But because their assessments feed decisions about benefits and rehabilitation eligibility, they also function as gatekeepers, categorising clients as worthy or unworthy of support. Drawing on the capability approach, the authors argue that this individual-level focus risks adapting people to a flawed system rather than challenging the system itself, echoing warnings in the literature that occupational therapy can become an agent of maintenance for existing social inequities. The participants themselves were not satisfied with the status quo: they called for assessments to move out of clinics and into real work environments, for unemployment and work ability to feature in professional education, and for the profession to shift from last resort to preventive measure. The authors conclude that occupational therapists could serve as a bridge between health, social and employment services, but caution that their insights rest on practitioner perspectives alone. Including the voices of unemployed people themselves, they write, is the crucial next step.

Subject of Research: Occupational therapy practices with unemployed people in Finland

Article Title: Occupational therapy practices among unemployed people in Finland

Article References: Turtiainen, T., Rosenberg, L., & Jansson, I. (2025). Occupational therapy practices among unemployed people in Finland. Scandinavian Journal of Occupational Therapy, 32(1), Article 2585856. https://doi.org/10.1080/11038128.2025.2585856

Image Credits: AI Generated

DOI: 10.1080/11038128.2025.2585856

Keywords: occupational therapy, unemployment, Finland, work ability, phenomenography, long-term unemployment, rehabilitation, capability approach, multisectoral collaboration, labour market, welfare services, occupational science

The Activity Calculator was developed by two occupational therapists from the Netherlands, Greke Hulstein–van Gennep and Karin ten Hove–Moerdijk, who recognized from their clinical experience that therapists needed a standardized, structured method to help patients with chronic fatigue participate in daily occupations in line with fatigue management recommendations. The method has since spread remarkably widely: certification courses have been organized for occupational therapists in the Netherlands since 2008 and in Norway since 2015, and more than 25 percent of all occupational therapists in the Netherlands and 8 percent of those in Norway have completed the training. Manuals are available in Dutch, Norwegian and English. That level of uptake, the researchers note, suggests the method fills a genuine clinical need. Yet until now, the tool has been criticized for lacking a solid theoretical foundation—a serious gap, since program theory describing how an intervention is expected to work, and under what conditions, is considered necessary before an intervention can be meaningfully evaluated.

The new paper, published open access in the Scandinavian Journal of Occupational Therapy by Irma Pinxsterhuis and Fanny Alexandra Jakobsen of Oslo Metropolitan University and Kirsti Nordstokkå of Sørlandet Hospital, addresses that gap by elaborating three core concepts from occupational therapy and occupational science: occupational adaptation, patterns of daily occupation, and occupational balance. The authors systematically discuss how each concept maps onto the phases of the Activity Calculator intervention, from evaluation and goal-setting through the intervention itself to re-evaluation. Their conclusion is that the three concepts appear to serve as a suitable theoretical foundation, providing a conceptual framework that may explain how the method helps people organize and adjust their everyday occupations to promote health, participation and well-being.

The Activity Calculator itself is a person-centred, time-contingent method. Patients begin by categorizing their usual activities as light, medium, strenuous or relaxing, then complete time registration lists for three to five representative days. Points are assigned to each activity according to its category and the time spent on it, and the total yields an activity level—the number of points the patient can manage in one day, whether it is a good day or a bad day. Patients then plan their activities against this budget using an app, activity cards, a pre-set day or week schedule, a diary, or an individually designed tool. This makes the approach time-contingent, in contrast to symptom-contingent approaches that assume patients have an accurate view of their capabilities and respond reliably to warning signs. Over time, activity levels can be increased gradually to avoid relapses or worsening of fatigue, and the calculator can eventually be retired once patients have internalized the planning habit.

The first theoretical pillar, occupational adaptation, is historically and philosophically rooted in occupational therapy but has been defined ambiguously in the literature. First described by Schkade and Schultz in 1992 as a normative process most pronounced in periods of transition, the concept has been reconceptualized by later researchers into clinically applicable language. In contemporary usage, occupational adaptation describes both a transactional process between the person, their occupations and the occupational environment, and an outcome of occupational participation. When a person encounters an occupational challenge—an obstacle or demand encountered while performing an occupation—it is the desire for occupational engagement that drives the adaptive response, linked to internal processes such as perception of choice, conscious awareness, self-reflection, problem-solving, acceptance and emotional regulation. Adaptation is a lifelong, cumulative, non-linear process, and people can learn from earlier experiences to support future adaptation.

Two measures of adaptation as an outcome are particularly relevant to the Activity Calculator. Relative mastery refers to a person’s subjective experience of competence in an occupation, assessed through effective participation, efficiency in using available personal and environmental resources such as time, energy and social supports, and satisfaction with occupational performance. Adaptive capacity, meanwhile, describes whether an individual has sufficient tools in their toolbox to respond to occupational challenges—including the ability to creatively develop new strategies when old ones fail. Some studies have shown positive associations between occupational adaptation and experiences of health and well-being, which matters because the two aims of the Activity Calculator explicitly target adaptation: helping patients find a balance between what they want to do and what they are able to do, and helping them obtain congruence between occupational participation and their values and personal meaning.

The second pillar, patterns of daily occupation, is often described as doing in time. Researchers have explored these patterns by categorizing occupations using taxonomies such as work, play, rest and sleep, or, in a scheme from Erlandsson and Eklund, distinguishing main occupations that dominate time and awareness, hidden occupations performed routinely, and unexpected occupations that interrupt the others. Other work has examined the complexity of 24-hour cycles, including duration, frequency, parallel occupations performed simultaneously, and the social coordination of occupations with other people. Diaries are a standard tool for documenting and reflecting on these patterns, and the Activity Calculator’s time registration lists function in exactly this way. Review of the lists reveals the prevalence of different occupation types, temporal aspects such as duration and frequency, perceived time pressure, orchestration of activities with others, and changes over time. Patients may also be asked to label registered activities as main, hidden or unexpected occupations, and perceptions can be complemented by significant others—for instance when patients are minors or have cognitive impairments.

The third pillar, occupational balance, is commonly defined as an individual’s perception of having the right amount of occupations and the right variation between them. A review by Eklund and colleagues identified three indicators: perception of the right variation and harmony between occupations, having the ability and resources for occupational engagement, and engagement in line with personal meaning and values. Jonsson and Persson proposed a tentative model in which balance is perceived through a relational mix of Exacting occupations that exceed actual skills, Flowing occupations with a reasonable match between skills and challenges, and Calming low-challenge experiences such as relaxation. A scoping review by Wagman and Håkansson added that occupational balance must be considered interpersonally, since it affects and is affected by partners, family members, employers and colleagues. The research base is striking: occupational balance is positively related to health, well-being, quality of life, life satisfaction and work ability, while imbalance has been linked to fatigue, stress and depression—one study finding that people with fatigue limited its consequences by applying adaptive strategies.

The authors’ discussion walks through how these concepts anchor each phase of the intervention. In the evaluation and goal-setting phase, occupational adaptation as a transactional process helps therapists identify occupational roles, role demands, occupational challenges and previously used responses, while assessments of relative mastery and adaptive capacity provide a picture of perceived adaptation. The Transtheoretical Model of Change, embedded in the Activity Calculator manuals, ensures the method is introduced only when patients have the intention and willingness to change, since decision-making about behaviour change depends on weighing the pros and cons of current behaviour. In the intervention phase, categorizing activities provides insight into the complexity of each patient’s daily patterns; registration reveals discrepancies between current occupational responses and perceived energy for mental or physical activity; and planning against the calculated activity level gives patients a framework for optimizing the relationship between time, energy and occupation. Patterns of daily occupation form the more objective, partly observable aspect of the framework, while occupational balance adds the subjective, emotional and personal dimension—and because the two constructs are interrelated, changes in one affect the other. Therapists support the process with education in energy conservation, spreading activities over the day and week, prioritizing and delegating, balancing engagement with rest, and modifying environments or adding assistive devices to make activities less strenuous.

At the end of the intervention, therapists assess the temptations and personal challenges patients face in maintaining adaptive occupational responses. Some patients continue to use the calculator indefinitely to maintain or improve their adaptation; others learn to engage without calculating points, responding to warning signs instead—taking a break, or switching to an activity that uses different muscles. At times of high risk, such as personal crises, social pressure, holidays or moving house, the calculator can be reintroduced, since these triggers may reactivate dysadaptive responses. Regular re-evaluation of patterns, balance, relative mastery and adaptive capacity detects when the activity level needs adjusting or new occupational responses need developing. The authors acknowledge that further research is needed to explore the relationship between using the Activity Calculator and improvements in health and well-being—but with this theoretical foundation in place, those studies can finally be designed on solid conceptual ground.

Subject of Research: A theoretical foundation for the Activity Calculator, an occupational therapy method for managing chronic fatigue through activity planning

Article Title: Theoretical foundation of the Activity Calculator – a method for fatigue management

Article References: Pinxsterhuis, I., Nordstokkå, K., & Jakobsen, F. A. (2025). Theoretical foundation of the Activity Calculator – a method for fatigue management. Scandinavian Journal of Occupational Therapy, 32(1), Article 2608471. https://doi.org/10.1080/11038128.2025.2608471

Image Credits: AI Generated

DOI: 10.1080/11038128.2025.2608471

Keywords: chronic fatigue, Activity Calculator, occupational therapy, occupational adaptation, occupational balance, patterns of daily occupation, energy conservation, pacing, long Covid, occupational science, fatigue management, rehabilitation

The study arrives at a moment of mounting concern in international sport. In 2023, the International Olympic Committee formally identified youth elite athletes as a ‘neglected population’ and issued a call for further research into their wellbeing. Despite the enormous investment that sporting systems pour into identifying and developing young talent, relatively little is known about how the process of becoming an elite athlete shapes the day-to-day occupational lives of adolescents and young adults. Previous work has leaned heavily on psychological frameworks, focusing on traits such as motivation, resilience and burnout, while paying less attention to how training regimes, relocation, institutional demands and social pressures restructure a young athlete’s entire pattern of living.

Methodologically, the research combined quantitative and qualitative evidence in a convergent mixed-methods design. A cross-sectional questionnaire captured data from 39 athletes, measuring dimensions of mental health alongside constructs such as enthusiastic commitment and grit. In parallel, the team conducted semi-structured individual interviews with eight athletes, gathering both the current experiences of young athletes on the talent pathway and retrospective accounts from more experienced athletes who had already lived through the transition. By analysing the two data streams side by side, the researchers could test statistical patterns in the sample while also building a richer narrative picture of what occupational balance, or the lack of it, actually looks like in the lives of developing athletes.

The quantitative results pointed to stark differences in mental health outcomes across the sample. Gender and sport type were both associated with psychological wellbeing: female athletes and athletes competing in individual sports reported poorer mental health than their male peers and those in team environments. This pattern is significant because it suggests that the structural and social conditions of different sporting contexts, rather than elite status alone, may shape psychological risk. Team sports may offer built-in social connection and shared identity, whereas individual sports can place the full weight of performance, travel and self-directed training on a single young person, with fewer companions to share the load.

One of the most technically interesting quantitative findings concerned the relationship between commitment quality and mental health. The researchers distinguished enthusiastic commitment, a form of engagement characterised by genuine enjoyment and willing dedication, from more constrained forms of commitment driven by obligation or entrapment. Enthusiastic commitment was positively correlated with grit, the persevering passion for long-term goals that psychologists have linked to achievement, and negatively correlated with depression. In other words, young athletes who pursued their sport out of love rather than pressure tended to be both more persistent and psychologically healthier. This distinction carries practical weight, because talent systems that rely on coercive or highly controlling selection pressures may inadvertently convert healthy dedication into a risk factor for depression.

The qualitative analysis, meanwhile, identified six key factors that influence occupational balance during the process of becoming an elite athlete. The first was the sheer scale of elite sport as a time commitment: training, competition, travel and recovery consumed the hours that peers spent on study, part-time work, hobbies and socialising. The second was relocation for recognition, as promising athletes moved away from home, often in adolescence, to access better coaching, facilities or selection opportunities, severing the familiar occupational routines and support networks of their home environments. These are not merely logistical inconveniences; from an occupational science perspective, they are disruptions to the pattern of meaningful activity that scaffolds identity and wellbeing during development.

The remaining factors exposed the uncomfortable commercial and institutional realities of youth sport. Athletes described being treated as a commodity, valued for their results and potential rather than as whole people, which shaped how they understood their own worth and their willingness to admit difficulty. Meaningful relationships emerged as a powerful protective force supporting life balance, with family, friends, coaches and partners helping athletes preserve a sense of self beyond performance. Access to formal support varied widely and mattered enormously, as did what the researchers termed superhuman barriers to help-seeking: an ingrained cultural expectation that elite athletes should be physically and mentally invincible, making it difficult to acknowledge fatigue, anxiety or distress without fearing that a place on the team, a scholarship or a contract might be jeopardised.

Taken together, the findings reframe athlete wellbeing as an occupational balance problem rather than purely an individual psychological one. Occupational balance, a core concept in occupational science and occupational therapy, refers to a healthful distribution of meaningful activities across a person’s life, including work, rest, play and social participation. When elite sport monopolises a young person’s occupational repertoire, displacing sleep, education, friendships and leisure, the conditions for depression and other mental health difficulties are quietly established. The study’s authors argue that this perspective exposes opportunities for imbalance that a purely psychological or performance-based framing can miss, and it opens a door for occupational therapy to contribute to sport as an emerging practice area, supporting athletes not just in their sporting roles but in their lives as students, family members and friends.

The implications reach well beyond the clinic. Sporting bodies, academies and national institutes invest heavily in the physical development of young athletes, yet this study suggests that investment must be matched by systems that protect whole-life balance, monitor the mental health of female athletes and competitors in individual sports, cultivate enthusiastic rather than coerced commitment, and dismantle the superhuman norms that silence help-seeking. For a population the International Olympic Committee has labelled neglected, the message of this research is clear: the making of an elite athlete is an occupation in the fullest sense, and if we want young people to reach the podium and flourish afterwards, we must support the entire balancing act, not just the performance that happens on the field of play.

Occupational science, the discipline underpinning this study, emerged in the late twentieth century when researchers began arguing that human health cannot be fully understood by examining symptoms in isolation from the everyday activities that structure people’s lives. Within this tradition, occupation refers not only to paid employment but to the full range of purposeful activities that fill a person’s days, from sleeping and eating to studying, socialising and training. Applying this framework to sport represents a relatively recent extension of the field, and the current study is notable for treating athletic development itself as an occupational transition, comparable in scope to the transitions into parenthood, retirement or chronic illness that occupational scientists have long studied.

The emphasis on transition is particularly relevant given what is known about adolescence and early adulthood as developmental windows. During these years, young people typically consolidate their identities through experimentation with multiple roles, build peer networks outside the family, and establish habits of self-care and study that persist into adult life. When a demanding elite pathway absorbs a disproportionate share of a young person’s time and identity resources during precisely this window, the developmental work of building a diversified occupational repertoire may be deferred or derailed. The retrospective accounts gathered from experienced athletes in the study are valuable in this respect, because they offer a view of how early occupational imbalance echoes across a sporting career rather than only how it feels in the moment.

The statistical associations reported in the questionnaire data also invite careful interpretation. Because the design was cross-sectional, the findings describe patterns present at a single point in time rather than causal pathways. It is possible, for example, that the poorer mental health reported by female athletes and those in individual sports reflects unmeasured differences in coaching environments, media exposure, injury burden or resource allocation, and longitudinal follow-up would be needed to disentangle these possibilities. The sample of 39 questionnaire respondents and eight interviewees, while rich in depth, is modest in size, which means the quantitative estimates should be read as indicative rather than definitive.

Even with these caveats, the convergence between the two data streams strengthens the overall picture. The statistical correlation between enthusiastic commitment and lower depression mirrors the qualitative accounts of athletes who described thriving when their sporting lives remained connected to genuine enjoyment and supportive relationships, and struggling when obligation and external evaluation dominated. This kind of mixed-methods agreement is often taken as evidence that a phenomenon is robust across different ways of knowing.

The authors also frame their work as a contribution to the growing conversation about mental health in elite sport, an area that has gained visibility as prominent athletes have spoken publicly about psychological distress. By grounding that conversation in occupational balance, the study offers sporting organisations a practical vocabulary for auditing their programmes, asking not only whether young athletes are performing, but whether their daily lives retain the breadth of activity, connection and rest that sustained wellbeing requires, both during their careers and after they eventually leave the podium behind.

Subject of Research: Occupational balance and mental health among youth athletes transitioning to elite sport

Article Title: Balancing Act: An Occupational Lens on the Process of Becoming an Elite Athlete

Article References: Wilson, J., Prichard, I., Petersen, J., & Stenner, B. (2026). Balancing Act: An Occupational Lens on the Process of Becoming an Elite Athlete. Scandinavian Journal of Occupational Therapy. https://doi.org/10.1007/s44474-026-00006-2

Image Credits: AI Generated

DOI: 10.1007/s44474-026-00006-2

Keywords: elite athletes, youth sport, occupational balance, mental health, occupational therapy, athlete wellbeing, grit, enthusiastic commitment, help-seeking, International Olympic Committee, mixed methods, occupational science