The Indian Journal of Occupational Therapy

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 53  |  Issue : 3  |  Page : 116--120

Development of occupational therapy activities of daily living index to assess basic activities of daily living in an Indian context: A prospective quantitative study


Parag R Adsule1, Akshata Mahale2, Sujata Jalmi2,  
1 Department of Occupational Therapy, Goa Medical College, Bambolim, Goa, India
2 Department of Occupational Therapy, Hospicio, District Hospital, Margao, Goa, India

Correspondence Address:
Parag R Adsule
Assistant Professor in Occupational Therapy, Department of Occupational Therapy, Goa Medical College, Bambolim
India

Abstract

Background: Activities of daily living (ADL) deficit is a common and significant problem after any condition. Many scales are more focused on assessing the patients' independence or dependence but are less understood on the different parameters such as importance and values of activity, satisfaction, ability to cope up, completion, and time taken for the activity. These parameters are not well defined in many ADL assessments. Objectives: The purpose of this index was to evaluate ADL not only based on independence but also to understand the patients' values, adequacy, safety, standard, and finally, acceptability. Study Design: A prospective quantitative study was conducted. Methods: We conducted prospective, quantitative study and developed a new scale. Items were generated from a review of literature, semi-structured interviews of adult as well as geriatric patients and discussions with experts were carried out. The new instrument was piloted among 290 patients with neurological and orthopedic conditions. Content validity, internal consistency, and test-retest reliability were evaluated. Results: The new scale has good internal consistency: Cronbach's alpha = 0.984 and KR20 value = 0.97. Test–retest reliability (intra-class correlation coefficient = 0.87) was found to be good. Conclusion: Our research analysis indicates that Occupational Therapy (OT) ADL index is reliable for rating the Basic ADL skills for functional deficits in neurological and orthopedic conditions in adults. The OT ADL index may facilitate an objective assessment in the OT domains of basic ADL.



How to cite this article:
Adsule PR, Mahale A, Jalmi S. Development of occupational therapy activities of daily living index to assess basic activities of daily living in an Indian context: A prospective quantitative study.Indian J Occup Ther 2021;53:116-120


How to cite this URL:
Adsule PR, Mahale A, Jalmi S. Development of occupational therapy activities of daily living index to assess basic activities of daily living in an Indian context: A prospective quantitative study. Indian J Occup Ther [serial online] 2021 [cited 2021 Dec 2 ];53:116-120
Available from: http://www.ijotonweb.org/text.asp?2021/53/3/116/328127


Full Text



 Introduction



In occupational therapy (OT) practice, the assessment of clients is considered an integral part of the therapeutic process as it dictates the treatment intervention pertaining to the client's specific goals based on assessed weaknesses and strengths. Occupational therapists' use of assessment and outcome measures that are congruent with their profession-specific values, beliefs, and principles show the profession's unique contribution.[1]

The various activities of daily living (ADL) measures used do not adequately capture the objectives of OT assessment and intervention as guided by the profession's values, beliefs, and principles.[2] Frequently ADL outcomes are based on generic scales of functional independence, such as the Functional Independence Measure (FIM). The use of generic scales allows the comparison of outcomes across diagnostic categories and among health-care providers but limits the recording of discipline-specific input.[3] Wæhrens reported when occupational therapists evaluate their clients' ADL abilities, they evaluate not just whether or not their clients are independent or require assistance and how much assistance they need but also consider the safety risk, decreased time-space organization of the task performance and/or increased physical effort or clumsiness related to the ADL task performance. Therefore occupational therapists evaluate ADL based on the quality of the ADL task performance.[4] The occupational therapist uses categorical, descriptive evaluation of perceived and observed ADL task performance among different diagnostic groups, focusing on those ADL tasks of relevance to the client's everyday life, and using same, the occupational therapists are free to define their own rating scales.[5]

So far, no studies have reported ADL ability data based on evaluation of the quality of ADL performance related to values, experiences, belief, coping up, satisfaction, amount of time, physical effort, safety risk and/or need for assistance in the Indian context. Therefore the purpose of this study was to develop a new scale, i.e. OT ADL Index, to evaluate the extent of various parameters to understand clients' everyday ADL skills.

 Methods



A prospective quantitative study was conducted for the development of a new scale. We have taken ADL as the dependent variable and age and sex as the independent variables.

Development of Occupational Therapy Activities of Daily Living Index

Item generation: We used both deductive and inductive methods for our item generation. Deductive methods involved item generation based on an extensive literature review and preexisting scales. On the other hand, inductive methods based item development on qualitative information regarding a construct obtained from opinions gathered from the target population.[6] The ten items of basic ADL used in the assessment were feeding, grooming, bathing, dressing upper limb, dressing lower limb, toilet activity, bed mobility, transferring to chair and back, walking, and stair use. These items were procured from the Barthel Index, Modified Barthel Index, FIM, Canadian Occupation Performance Measure, and Assessment of Motor Process Skills.[7],[8],[9],[10]

Parameters for OT ADL Index: Parameters of activity are part of the operational definitions of activity and direct attention to the dimensions of ADL that are to be evaluated.[11] Parameters of activity performance may be evaluated by qualitative (descriptions, observations) and quantitative (nominal, ordinal, interval, ratio) approaches.

Extensive review of the literature was conducted to support each parameter of our new scale. We used different receiver guidelines to help formulate different parameters used in our new scale, as mentioned in [Table 1].{Table 1}

Content Validity

Content or face validity of the scale was established by reviewing its components with the experts. Five occupational therapists with at least 3 years of experience were selected. A copy of the scale developed was distributed to the experts for their feedback. They were requested to provide written comments about the purpose, objective, population selection, test items, and scoring techniques.

Once these suggestions and remarks were obtained from the experts, we reviewed a few items and ratings in our scale, and also appropriate reasons were communicated to the experts regarding the acceptance as well as nonacceptance of their suggestions.

Finalization of Occupational Therapy Activities of Daily Living Index

The items were broadly categorized into ten components of basic ADL skills, including feeding, grooming, bathing, toilet activity, dressing upper limb, dressing lower limb, bed mobility, transferring from bed to chair and back, walking, and stair use; to be assessed on the ten different parameters. The final version was in English. This index was used as a self-report, caregiver report, and interview to capture the participants' perspectives on the basic ADL task performance. In our scale, 3 point scoring was formulated for assessment, rated from 0 to 2. Overall 0 was considered as independent and 2 as dependent, which meant higher the score, more is the encountered difficulty, and lower the score, lesser the difficulty and more is the independence. The maximum score was 200 and minimum score was 0 for all components combined with all 10 parameters, with the total score for each activity being 20, as mentioned in [Table 1]. The items fit the local cultural and OT settings. All the items were distinct, with each item containing only one question, which was easy to understand.

The study was conducted on the population of Goa in Goa Medical College. The 290 participants included had either neurological conditions such as stroke, head injury, Parkinson's disease, Guillain-Barré syndrome, multiple sclerosis, spinal cord injuries, or orthopedic conditions like upper limb and lower limb fractures. We included adult and geriatric population of both genders with ages ranging from 18 to 75 years. We excluded participants and caregivers on grounds of inadequate English comprehension ability and on their unwillingness to participate in the study.

The study was conducted adhering to the principles of the Declaration of Helsinki guidelines. The participants were explained about the study objective and their written informed consent was obtained. They were then asked for their demographic information, including age, gender, marital status, and living situation. We also recorded medical information related to their condition. Then, the participants were asked the questions in the scale and their responses were recorded and appropriately scored. Later, data were maintained and analyzed for psychometric properties.

Data Analysis

Data were analyzed using descriptive analysis with respect to participant characteristics, variables and ratings. In addition, we analyzed the internal consistency using Cronbach's alpha, and Kuder–Richardson (KR) 20 was used to assess test–retest reliability (n = 30).

 Results



Demographic Information

The total cases in neurological conditions 196 (67.5%) comprised 55 females (26%) and 141 males (74%) and in orthopedic conditions 94 (32.5%) comprised 36 females (38%) and 58 males (62%).The results show that the percentage of males was more than that of females in both neurological and orthopedic conditions. The percentages of age group distribution are shown in [Table 2].{Table 2}

Psychometric Properties of Occupational Therapy Activities of Daily Living Index

The reliability and internal consistency of the OT ADL Index in Neurological conditions were measured by Cronbach's alpha value and by KR 20, which were 0.983 and 0.97, respectively, indicating high internal consistency. The internal consistency values ranged from 0.78 to 0.85.

On the other hand, the reliability and internal consistency of OT ADL Index in Orthopaedic conditions were measured by Cronbach's alpha value and by KR 20, which were 0.984 and 0.97, respectively, indicating high internal consistency. The internal consistency values varied from 0.85 to 0.93. Overall the analysis showed correlation and consistency [Table 3].{Table 3}

The test-retest reliability was 0.87 (intra-class correlation coefficient) from the test on Day 1 to retest on Day 15. The analysis showed correlation and internal consistency; the mean score was also calculated, as shown in [Table 4].{Table 4}

[Table 5] shows the distribution of participants among the various neurological and orthopedic diagnoses as well as the mean scores obtained by each diagnostic category.{Table 5}

 Discussion



As explained earlier, many parameters such as importance and values of activity, satisfaction, ability to cope up, completion, and time taken for the activity are not well defined in many ADL assessments. Our new scale aimed to evaluate ADL not only based on independence but also based on the participants' values, adequacy, safety, standard, and finally, acceptability for its utility in the Indian context.

The parameters of the activity performance that occupational therapists are most interested in are values, independence, safety, and quality. Hence, the purpose of this index was to evaluate ADL not only in terms of dependence or independence but also to understand participants' values, adequacy, safety, standard, and finally, acceptability.

The Fisher and Short-DeGraff scaling type approach suggested that the development of an index was best on the delineation of hierarchies and the practitioner can anticipate considered advances in regard to their future.[12] This was considered while constructing our OT ADL Index. It helped us understand the deficits in ADL in terms of values, standards, adequacy, efficiency, physical and nonphysical assistance, and difficulties. These strongly suggested a need of OT intervention and supportive services for ADL skills with different neurological and orthopedic conditions.

We considered suitable instructions, an appropriate number of items, adequate display format and appropriate item redaction as all items should be simple, clear, specific as well as ensure the variability of response and maintenance of hierarchy.

The opinions of expert therapists in the research were also sought to ensure appropriate representativeness of the construct of items to reflect the participants' engagement in OT. The items fit the local cultural and OT settings. All the items were distinct with each containing only one question which was easy to understand.

We tested the reliability of our scale which showed good coefficient alpha (0.87) and KR20 value was 0.97. We also tested the internal consistency which ranged from 0.78 to 0.85. These analyses can be used to make sound judgement regarding each item. Reliability to a large extent reflected adequacy of the items since its calculation depends on the score achieved by the participant on the items in the pilot study.

Our scale involved subjective responses which may be a limitation for every questionnaire base scale. Even so, our index helped understand the various aspects of participants in detail and their views about ADL rather than the therapist anticipating responses about the condition of the participants as the participants responses measure their ADL abilities more appropriately and accurately.

It was observed that some participants had difficulty in responding to a few questions which necessitated an in-depth explanation of these questions. This may be because of the low literacy level of the participant or because the administrator had higher expectation from the participant. There was a need to translate in different local languages. The local population generally understood English, but this scale definitely requires translation for future use.

It is recommended that the test-retest reliability, interrater reliability, and validity be further tested for specific diagnoses. Further correlation testing with the various assessment scales which assess the ADL skills and activities may also be required.

Our study reveals that this scale can be used to learn about the participants activity performance based on the participants' needs and preferences. This scale makes it easy to investigate each ADL in detail with respect to decision-making for intervention and outcome. Finally, it may help understand what participants wish to do, are required to do, and are accepted to do.

 Conclusion



Deficits in ADL are inevitable and a significant problem area after any health condition. OT has the potential to help people with their ADL skills. The standardized assessments developed in other population are limited in terms of their utility in the Indian context.

Our study indicates that the OT ADL index is reliable for rating the BADL skills in adults with neurological and orthopedic conditions. The OT ADL index may facilitate an objective assessment in the OT domain and may contribute to practice and research.

Acknowledgment

The authors express their heartfelt thanks to the participants and the expert reviewers for their kind co-operation and valuable input, which helped in developing this assessment scale. We are grateful to Dr. Vivek P. Vajaratkar, BOT In-charge GMC Goa for his constant support and we express a deep sense of gratitude toward Dr. S. M. Bandekar, Dean, Medical Superintendent and Head of Department of Orthopaedic Surgery, GMC Goa. We also thank Dr. Manoj Kumar Kulkarni and Dr. Charmaine Almeida for their help in the completion of this study.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

References

1Kielhofner G. Volition. In: Kielhofner G, editor. Model of Human Occupation: Theory and Application. 4th ed. Baltimore: Lippincott Williams and Wilkins; 2008. p. 32-50.
2Gutman SA. The domain of function: Who's got it? Who's competing for it? Am J Occup Ther 1998;52:684-689.
3Heinemann AW. Functional status and quality of life measures. In: Elliot TR, editor. Handbook of Rehabilitation Psychology. Washington, DC: American Psychological Association; 2000. p. 261-286.
4Waehrens EE, Fisher AG. Developing linear ADL ability measures based on the ADL taxonomy: A Rasch analysis. Scand J Occup Ther 2009;16:159-171.
5Morgado FF, Meireles JF, Neves CM. Scale development: Ten main limitations and recommendations to improve future research practices. Psicol Reflex Crít 2018;30:3-5.
6Guide for the Uniform Data Set for Medical Rehabilitation (Including the FIM™ Instrument). Ver. 5.1. Buffalo, NY 14214-3007: State University of New York at Buffalo; 1997.
7Mahoney FI, Barthel DW. Functional evaluation: The barthel index. Md State Med J 1965;14:61-65.
8Law M, Baptiste S, Carswell A, McColl MA, Polatajko H, Pollock N. The Canadian Occupational Performance Measure. 4th ed. Toronto, ON: CAOT Publications; 2005.
9Fisher AG, Jones KB. Assessment of Motor and Process Skills. Vol. 1: Development, Standardization, and Administration Manual, 7th ed. Fort Collins, CO: Three Star Press; 2010. p. 1-5.
10Eakin P. Problems with assessments of activities of daily living. Br J Occup Ther 1989;52:50-54.
11Allen CK, Gage M, Noh S, Polatajko HJ, Kespar V, Russell C, et al. Activities of daily living and instrumental activities of daily living. In: Willard and Spackman's Occupational Therapy. 11th ed. Philadelphia: Lippincott Williams and Wilkins; 2009. p. 577 562.
12Fisher AG, Short-DeGraff M. Improving functional assessment in occupational therapy: Recommendations and philosophy for change. Am J Occup Ther 1993;47:199-201.