The original EHFScBS-C is a nine-item questionnaire built around a two-factor structure: one factor captures medical self-care behaviours, such as ensuring the patient takes medication correctly and recognizes worsening symptoms, while the other captures lifestyle self-care, including diet, physical activity, and daily weighing. The scale has become a standard measure in European research, but a questionnaire is not simply a list of questions that can be translated word for word. Concepts such as self-care, symptom monitoring, and even the role of family members in medical decision-making carry cultural weight, and a poorly adapted instrument can produce misleading scores. The research team therefore set out to translate, culturally adapt, and statistically test the scale for use among Iranian caregivers, a process known in the field as psychometric evaluation.

The study was designed as a cross-sectional methodological investigation, the standard architecture for validation research. Between October 2023 and February 2024, the researchers recruited 260 informal caregivers of heart failure patients at Ayatollah Mousavi Hospital in Zanjan, Iran, using convenience sampling. Before any data were collected, the team carried out forward and backward translation: the scale was first rendered from English into Persian by translators, then independently translated back into English, and the two versions were compared to detect distortions in meaning. This iterative procedure, followed by expert review, is the accepted method for ensuring that a translated questionnaire asks the same questions as its original.

Face and content validity came first. Content validity asks whether the items genuinely cover the domain the scale claims to measure, and it is typically quantified with content validity indices in which experts rate the relevance of each item. In this study, the scale-level average content validity index reached 0.95, an exceptionally high value on a metric where values above 0.90 are generally considered excellent. That figure suggests the expert panel judged nearly every item to be clearly relevant and unambiguous in the Persian cultural context, with no items requiring substantive revision or deletion.

The centrepiece of the study was confirmatory factor analysis, or CFA, a statistical technique that tests whether the pattern of correlations among questionnaire items matches a predefined theoretical structure. Unlike exploratory factor analysis, which searches for structure in the data, CFA imposes the original two-factor model — medical self-care and lifestyle self-care — and asks how well it fits. The researchers evaluated fit using several complementary indices, each capturing a different aspect of model adequacy. The ratio of chi-square to degrees of freedom was 1.64, comfortably below the conventional threshold of 3. The root mean square error of approximation, or RMSEA, was 0.049, beneath the 0.05 benchmark that signals close fit. The comparative fit index and the Tucker-Lewis index came in at 0.984 and 0.978 respectively, both far above the 0.95 cutoff. Taken together, these numbers indicate that the two-factor structure of the original European scale survived translation into Persian essentially intact.

Item-level statistics reinforced that conclusion. All nine items showed statistically significant factor loadings, meaning each item reliably contributed to its intended factor, with loadings ranging from 0.407 to 0.912. Notably, the researchers did not need to remove a single item to achieve good fit, which is uncommon in cross-cultural validation work, where weak items are frequently dropped. Preserving the full nine-item structure matters practically: it means scores from the Persian version can be interpreted in the same way as scores from the original instrument, enabling meaningful comparison across studies, countries, and languages.

The team also examined convergent and discriminant validity, two complementary tests of whether the scale measures what it claims and nothing else. Convergent validity asks whether items theorized to reflect the same construct correlate strongly with one another; discriminant validity asks whether distinct constructs, such as the medical and lifestyle factors, remain statistically separable rather than collapsing into a single undifferentiated blob. The Persian scale established acceptable performance on both fronts, supporting the interpretation of two related but distinct dimensions of caregiver contribution.

Reliability — the consistency of measurement — was assessed in two ways. Internal consistency, which reflects how coherently items within a scale hang together, was quantified with both Cronbach’s alpha and McDonald’s omega, two statistics that approach the same question from slightly different assumptions. The overall scale achieved a Cronbach’s alpha of 0.834 and a McDonald’s omega of 0.894, with the subscales also showing strong values; both figures sit well within the range regarded as good for a short clinical instrument. Test-retest stability was evaluated by readministering the scale to participants after a two-week interval and computing the intraclass correlation coefficient, which came out at 0.89. An ICC of that magnitude indicates that caregivers’ scores were highly stable over time, exactly what one would expect from a measure of habitual behaviour rather than a fleeting mood state.

Why does this matter beyond the statistics? Heart failure is one of the most burdensome chronic conditions worldwide, and readmission rates remain stubbornly high in many health systems, often because patients fail to adhere to the demanding self-care regimen the condition requires. Caregivers are the hidden workforce that makes adherence possible, yet family-centred interventions can only be evaluated if caregiver contribution can be measured accurately. A validated Persian version of the EHFScBS-C gives Iranian clinicians and researchers a trustworthy tool for identifying caregivers who need support, tailoring education programmes, and evaluating whether family-centred heart failure management actually improves outcomes. The authors conclude that the nine-item scale is robust, valid, and reliable in the Iranian context, and its structural stability without item deletion makes it a practical addition to clinical practice and research. The study, published open access under a Creative Commons licence, was approved by the Institutional Review Board of Zanjan University of Medical Sciences and conducted in accordance with the Declaration of Helsinki, with written informed consent from all participants. For the millions of families quietly managing heart failure at home, this work represents a small questionnaire with a large consequence: the daily labour of love that keeps patients stable can finally be seen, measured, and supported.

Subject of Research: Psychometric validation of the Persian version of the European Heart Failure Self-Care Behaviour Scale for Caregivers

Article Title: Psychometric evaluation of the persian version of the EHFScBS-C: a confirmatory factor analysis

Article References: Yadegary, M. A., Aghajanloo, A., Shaabani, M., Masaebi, F., & Seyednazari, M. A. (2026). Psychometric evaluation of the persian version of the EHFScBS-C: a confirmatory factor analysis. BMC Nursing, 25(1), Article 913. https://doi.org/10.1186/s12912-026-05404-2

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05404-2

Keywords: heart failure, caregivers, self-care, psychometrics, validation study, confirmatory factor analysis, EHFScBS-C, Iran, nursing research, reliability, questionnaire translation, family-centred care

Work-life balance is not the same thing as working fewer hours or splitting time fifty-fifty. The researchers are careful to define it as an individual’s overall, subjective appraisal of how well work and non-work activities fit together in relation to current priorities and opportunities for growth. Someone who works long hours but finds the arrangement satisfying and aligned with their goals can genuinely perceive balance, while someone with a lighter schedule may feel deeply out of sync. This distinguishes the construct from related theories in organizational psychology, such as work-family conflict, which focuses on incompatible demands between roles, and work-family enrichment, which describes how resources gained in one domain can benefit another. The spillover-crossover model adds a further layer, describing how experiences and emotions travel between work and home within one person, and even between partners and family members.

The scale at the heart of the new study was developed by Paula Brough and colleagues, who designed a concise four-item measure based on people’s global subjective evaluation of the balance between work and non-work activities. Unlike conflict measures, which ask whether demands in one domain interfere with functioning in another, the scale asks respondents to judge the perceived balance itself, and it was built to apply regardless of marital or parental status. In the original validation across four heterogeneous samples of workers in Australia and New Zealand, the one-factor structure and internal consistency held up, and work-life balance was associated in expected directions with work demands, job and family satisfaction, turnover intentions, and psychological strain, with several associations replicated over time. What was missing was any Swedish version, which limited researchers and practitioners who wanted a brief, well-grounded measure for large work-life health studies in Sweden.

Producing one required far more than dictionary work. The team followed the ISPOR guidelines for cross-cultural validation of instruments, a staged process designed to protect conceptual equivalence rather than literal wording. Two native Swedish speakers produced independent forward translations after being briefed on the constructs, the target population, and the purpose of the instrument, and they were explicitly instructed to prioritize culturally appropriate meaning over word-for-word fidelity. Their versions were reconciled item by item into a single draft, which was then translated back into English by two researchers who had not been involved in the forward translation. The back translations served as a diagnostic mirror, revealing ambiguities or unintended shifts in meaning, and a harmonization review compared the preliminary Swedish version, the original English scale, and both back translations across every item, instruction, and response alternative.

The most revealing stage was cognitive debriefing, in which eight Swedish-speaking participants — police officers, civilians working within the police authority, and a public order officer — completed the draft version and were asked to think aloud about their understanding of the instructions, items, key terms, and response alternatives. Their feedback caught several expressions that were technically correct but felt unnatural in Swedish. The wording corresponding to “I believe” in the final item was judged overly literal and revised to emphasize the respondent’s subjective experience of balance, while the phrase corresponding to “about right” was replaced with a more idiomatic formulation. Interestingly, participants suggested removing the temporal and summary expressions corresponding to “currently” and “overall,” but the researchers declined, judging those words to be meaningful components of the original items and essential to preserving conceptual equivalence with the source instrument.

With the adapted scale finalized, the team turned to psychometric evaluation using survey data from 215 students — 173 in police education programs at three universities and 42 in an educational program within the Swedish Prison and Probation Service. Because the respondents were students, the questionnaire opened with the clarification that “if you are a student, work means your studies.” Items are rated on a five-point scale from strongly disagree to strongly agree, with one negatively worded item reverse-coded before scoring. The mean scale score came out at 3.85 on the five-point range, with a standard deviation of 0.85, and all four items used the full response range. Internal consistency was good, with Cronbach’s alpha of 0.83 and McDonald’s omega of 0.86, comfortably above the 0.70 threshold conventionally regarded as acceptable.

Not every item performed equally, however, and the study is unusually candid about this. The scale’s single reverse-worded item showed a corrected item-rest correlation of just 0.39, compared with 0.75 to 0.79 for the three positively worded items, and removing it would have pushed alpha up to 0.91. In the confirmatory factor analysis, which treated the items as ordinal indicators and used diagonally weighted least squares estimation, the positively worded items loaded strongly at 0.88 to 0.96 while the reverse-worded item loaded at only 0.49. The model’s overall fit was mixed but generally acceptable, with an SRMR of 0.01, an RMSEA of 0.07, and CFI and TLI values of 1.0, though the scaled chi-square test reached significance. The researchers note that reverse-worded items can introduce method variance by forcing respondents to shift response direction, raising the risk of cognitive burden or misinterpretation — and the same item also performed comparatively weakly in the original validation, a pattern consistent with, though not proof of, a wording-related effect.

Crucially, the team chose not to simply delete the problem item, even though doing so would have improved the reliability statistics. Dropping it would have altered the original four-item measure, and a three-item version has never been independently validated. Instead, they recommend that Swedish users retain all four items and the original scoring to preserve comparability, while reporting item-level performance and interpreting the reverse-worded item cautiously. Future studies, they suggest, could directly compare the reverse-worded item with a semantically equivalent positively worded alternative, or apply item response theory in larger and more occupationally diverse samples to clarify whether all four items contribute distinct information across the balance continuum.

The validity evidence was otherwise encouraging. Work-life balance correlated strongly and positively with occupational balance, measured with the Swedish-born Occupational Balance Questionnaire, at r = .76 — supporting convergent validity, though the magnitude also reveals substantial overlap between the two constructs and raises questions about how distinct they really are. The scale also behaved as theory predicts in relation to mental health: higher work-life balance was associated with lower depressive symptoms on the PHQ-9 (r = −.54) and lower anxiety symptoms on the GAD-7 (r = −.45), both statistically significant and of at least moderate magnitude. These findings echo the original validation, in which higher work-life balance predicted lower psychological strain both cross-sectionally and longitudinally, and they extend the evidence to more specific indicators of psychological distress.

The authors are clear about the limits. The sample consisted of students in professional education rather than employees exposed to long-term occupational demands, which may explain why 15.8 percent of participants hit the maximum score, producing a modest ceiling effect that could limit the scale’s ability to distinguish people at the upper end of balance. The cross-sectional design cannot establish whether low balance causes distress or the reverse, and no data were collected on test-retest reliability, measurement invariance, responsiveness, or predictive validity. The translation process also involved no bilingual professionals or translation agency, leaving open the possibility of translator-related bias despite the systematic procedure. Still, the study delivers what it promised: a brief, carefully adapted Swedish measure with promising initial psychometric properties, ready to be embedded in larger surveys of health, work ability, and working conditions — and, with further validation in broader working populations, potentially a small but powerful tool for understanding one of the defining tensions of modern working life.

Subject of Research: Translation and psychometric validation of the Swedish Work-Life Balance Scale

Article Title: Translation, cross-cultural adaptation, and psychometric evaluation of the Swedish Work-Life Balance Scale

Article References: Degerstedt, F., Bellander, S., Ingrell, J., Tedeholm, P. G., Nordin, T., & Granholm Valmari, E. (2026). Translation, cross-cultural adaptation, and psychometric evaluation of the Swedish Work-Life Balance Scale. BMC Psychology, 14(1), Article 1462. https://doi.org/10.1186/s40359-026-05752-3

Image Credits: AI Generated

DOI: 10.1186/s40359-026-05752-3

Keywords: work-life balance, psychometrics, cross-cultural adaptation, scale validation, internal consistency, confirmatory factor analysis, occupational balance, depression, anxiety, Sweden, questionnaire translation, occupational psychology

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