Validation of the Persian Version of the Engagement in Meaningful Activities Survey (EMAS) in an Iranian Stroke Population: Predictors of Participation in Meaningful Activities

Abstract

Importance: The inability to participate in meaningful activities is one of stroke survivors’ main difficulties and has a negative effect on their satisfaction and quality of life.

Objective: To assess the reliability and validity of the Persian version of the Engagement in Meaningful Activities Survey (EMAS–P) and predictors of participation in meaningful activity among chronic stroke survivors.

Design: Cross-sectional.

Setting: Medical and rehabilitation centers.

Participants: One hundred twenty-three people (75 men, 48 women) with chronic stroke.

Outcomes and Measures: Participants were evaluated with the EMAS–P, Satisfaction With Life Scale (SWLS), Center for Epidemiologic Studies Depression Scale, Purpose in Life Test–Short Form (PIL–SF), 36-Item Short Form Health Survey (SF–36), and Life Satisfaction Index–Z (LSI–Z).

Results: The EMAS–P showed good internal consistency (Cronbach’s α = .95) and test–retest reliability (intraclass correlation coefficient = .87 for EMAS–P total score). Test–retest reliability for each EMAS–P item was moderate (κ = .40–.65). A significant correlation between the EMAS–P and PIL–SF (r = .86), SWLS (r = .83), LSI–Z (r = .75), and SF–36 subscales (rs = .52–.83) indicated the appropriate convergent validity. The EMAS–P’s discriminative validity was also confirmed for age, depression level, and disability level among people with chronic stroke. Depression, disability level, gender, and fatigue were significant predictors of EMAS–P score.

Conclusions and Relevance: The results indicate that the EMAS–P has acceptable reliability and validity among Iranian people with chronic stroke. Moreover, the EMAS–P showed good discriminant validity for age, depression, and disability level among them.

What This Article Adds: The EMAS–P is a reliable and valid scale for assessing the engagement of Iranian chronic stroke survivors in meaningful activities and thus should be helpful in both clinical research and practice.

The results of this study show that the Engagement in Meaningful Activities Survey (EMAS) is a reliable and valid scale for assessing the engagement of chronic stroke survivors in meaningful activities, supporting its use in clinical research and practice.

Meaningful activities are defined as culturally and personally significant activities that people participate in, including work, domestic chores, family life–related activities (e.g., caring for others), and leisure time activities (e.g., active activities such as sport and passive activities such as reading, social meetings, and hobbies; Brożek & Tokarz, 2017; Hasselkus, 2011). The need for meaningful activities is part of human nature, and engagement in these activities provides structure to life and opportunities for enjoyable experiences (Gustafsson & McKenna, 2010). People who engage more in meaningful activities experience higher levels of psychological and physical well-being and life satisfaction than those who engage less in these activities (Kim et al., 2015).

Stroke causes a wide range of physical, cognitive, and psychological changes, resulting in impaired participation and engagement in meaningful activities (Lapadatu & Morris, 2019), and its correlation with quality of life, well-being, life satisfaction, purpose in life, and perceived health has been well established (Egan et al., 2014; Lewis et al., 2020; Tse et al., 2017). Moreover, level of physical disability, cognitive dysfunction, depression, fatigue, pain, gender, and age have been reported as important factors that affect the engagement of people with stroke in meaningful activities (van Almenkerk et al., 2015; Wassenius, 2020).

Stroke survivors need to be engaged in meaningful activities (Serfontein et al., 2020). However, they report decreased engagement in meaningful activities even 6 mo or longer after a mild stroke (Nicholas et al., 2020). Given the significance of participation in meaningful activities, having a suitable tool for its evaluation is of particular importance. Participation in meaningful activity can be assessed in different ways, such as by using self-report measures, examining the frequency of participation in meaningful activities, or determining the value that activities have for the person (Prat et al., 2019). Unfortunately, tools to assess stroke survivors’ participation in meaningful activities are limited.

One specific tool for the evaluation of participation in meaningful activities is the Engagement in Meaningful Activities Survey (EMAS), which was developed by Goldberg et al. (2002) for people with severe mental illness. It measures the extent of involvement in meaningful activities by means of a self-rated Likert scale. The EMAS consists of 12 items whose content was derived mainly on the basis of criteria mentioned in the occupational therapy literature (Eakman et al., 2010). The EMAS items reflect a broad conceptualization of the meaning of activity, emphasizing “the activity’s congruity with one’s value system and needs, its ability to provide evidence of competence and mastery and its value in one’s social and cultural group” (Goldberg et al., 2002, p. 19). Good internal consistency (Cronbach’s α = .84) and moderate test–retest reliability (r = .69) have been reported for the original EMAS (Goldberg et al., 2002).

Eakman et al. (2010) also investigated the EMAS’s reliability and validity in the older adult population. The EMAS has also been translated into French, Spanish, and Polish and is used in different cultures and countries (Brożek & Tokarz, 2017; Lacroix et al., 2018; Prat et al., 2019). However, a scale cannot be used with a specific population without evidence of its reliability and validity (Souza et al., 2017), so an investigation of the reliability and validity of the EMAS with stroke survivors was needed. Therefore, in this study, we aimed to validate a Persian version of the EMAS (EMAS–P) in assessing the engagement in meaningful activities of Iranian stroke survivors. Moreover, we aimed to examine whether different demographic and clinical variables predicted EMAS–P scores among this population.

Method

Participants

For this cross-sectional study, we recruited 123 chronic stroke survivors admitted to medical and rehabilitation centers in Tehran by means of a convenience nonprobability sampling method. Patients were included if they met the following inclusion criteria: (1) neurologist-confirmed diagnosis of stroke based on neuroimaging examination, (2) first onset of stroke ≥6 mo before participation in the current study, (3) adequate cognitive function to understand the questionnaires and instructions (i.e., a score of ≥24 on the Mini-Mental State Examination; Delavaran et al., 2017), and (4) ability to communicate verbally with the examiner. The exclusion criteria were as follows: (1) having orthopedic, rheumatologic, or other neurological comorbidities; (2) recurrence of stroke between test and retest assessments; and (3) failure to complete the retest. The study was approved by the Ethics Committee of the Iran University of Medical Sciences (IR.IUMS.REC.1398.106). All participants were provided with a detailed participant information sheet and provided written informed consent.

Procedure

Translation

Translation of the EMAS into Persian was conducted according to the forward–backward translation protocol. No changes were made to the EMAS as a result of the translation process.

Psychometric Properties

To investigate the validity and reliability of the EMAS–P, the participants (N = 123) completed the EMAS–P, Satisfaction With Life Scale (SWLS), Center for Epidemiologic Studies Depression Scale (CES–D), Life Satisfaction Index–Z (LSI–Z), Purpose in Life Test–Short Form (PIL–SF), 36-Item Short Form Health Survey (SF–36), a modified Rankin Scale (mRS), a pain visual analog scale (PVAS), and a visual analog scale–fatigue (VAS–F), in random order. In line with previous studies (Eakman et al., 2010), we selected this broad range of scales (i.e., SWLS, CES–D, LSI–Z, PIL–SF, and SF–36) to examine constructs theoretically related to meaningful activity. Moreover, level of physical disability, fatigue, and pain have also been reported as important factors that affect stroke survivors’ engagement in meaningful activities (Flinn & Stube, 2010; Pedersen et al., 2019; van Almenkerk et al., 2015; Wassenius, 2020). Thus, we also included the mRS, PVAS, and VAS–F. The first author (Moslem Cheraghifard), who has been working in the field of neurological rehabilitation for 7 yr, performed evaluations on 2 consecutive days. All participants were given a rest interval of 3 to 5 min between the consecutive evaluations. If necessary, participants were given an additional rest interval to prevent physical and mental fatigue. To assess the test–retest reliability of the EMAS–P, 38 participants were randomly selected and reevaluated with this questionnaire after 2 wk (Eakman, 2011; Eakman et al., 2010).

Instruments

The EMAS examines the extent to which one’s activities are congruent with one’s own values and those of one’s social environment. Each item begins with “The activities I do” and is followed by a range of feelings, such as “express my creativity” and “are valued by other people.” Each item is scored on a 5-point Likert scale ranging from 1 (never) to 5 (always), yielding a total score of 12 to 60; higher scores indicate higher perceived participation in meaningful activity (Eakman et al., 2010; Goldberg et al., 2002).

The SWLS (a 5-item measure with a total score ranging from 5 to 35) and the LSI–Z (a 13-item questionnaire with a total score ranging from 0 to 26) measure life satisfaction, with higher scores indicating greater life satisfaction. High test–retest reliability has been reported for the Persian versions of the SWLS (intraclass correlation coefficient [ICC] = .93; Tagharrobi et al., 2012) and LSI–Z (ICC = .93; Tagharrobi et al., 2011).

The CES–D includes 20 items (total score = 0–60), and higher scores indicate more severe depression. High test–retest reliability (ICC = .92) has been found for the Persian version of the CES–D (Nazemian et al., 2008). The PIL–SF includes 4 items that assess perceived meaning and life purpose. Scores on the PIL–SF score range from 4 to 28, with higher scores indicating a higher level of perceived meaning and life purpose. The Persian version of the PIL–SF showed good internal consistency (Cronbach’s α = .92; Cheraghi et al., 2009).

The SF–36 consists of 36 items in eight health-related subscales: general health, physical functioning, role limitations due to physical health, role limitations due to emotional problems, energy–fatigue, bodily pain, social functioning, and emotional well-being. Scores on each SF–36 subscale and the total score range from 0 to 100, and higher scores indicate better health-related quality of life. The SF–36 has good intrarater (ICC = .89) and test–retest (ICC = .89) reliability among chronic stroke survivors (Cabral et al., 2012). Good reliability (Cronbach’s α = .87) has also been reported for the Persian version of the SF–36 (Motamed et al., 2005).

The mRS is a widely used clinician-reported scale of global disability among stroke survivors. It consists of an ordinal scale that ranges from 0 (no symptoms at all) to 5 (severe disability), based on the level of disability, mobility, and dependency in activities of daily living (Banks & Marotta, 2007).

The PVAS asks respondents to rate the severity of their pain by placing a mark on a 10-cm printed line on which 0 = no pain and 10 = maximum pain. The PVAS has good test–retest reliability (ICCs = .71–.99; Kahl & Cleland, 2005). The VAS–F similarly asks respondents to place a mark on a 10-cm line at the point that indicates their fatigue intensity on which 0 = no fatigue and 10 = very severe fatigue. The VAS–F has acceptable test–retest reliability (ICC = .85) among stroke survivors (Tseng et al., 2010).

Statistical Analysis

The sample size needed to investigate the validity of the EMAS–P was calculated according to an item-to-respondent ratio of 1:10 (Naqvi et al., 2019). The EMAS has 12 items, so the required sample size was 120 respondents. We obtained data from 123 chronic stroke survivors. Moreover, the sample size required for test–retest reliability was determined on the basis of the functional approximation method provided by Walter et al. (1998). On the basis of the predicted reliability coefficient of .912 for the EMAS–P obtained in a pilot study, the minimum acceptable coefficient of .8 (Portney & Watkins, 2009), power of 80%, α level of .05, and two testing sessions, a minimum sample size of 33 was required.

The results of a Kolmogorov–Smirnov test showed a normal distribution of data. Test–retest reliability of the EMAS–P was investigated using ICC_(2,1) and 95% confidence intervals (CI). An ICC value >.75 indicates excellent reliability (Lue et al., 2018). Internal consistency was assessed with Cronbach’s α, and a value >.7 was considered acceptable. Measurement error was evaluated using standard error of measurement (SEM) and minimal detectable change (MDC). Floor and ceiling effects were also calculated, and values <15% were considered acceptable (Terwee et al., 2007).

To investigate construct validity, Pearson correlation coefficients were calculated between the EMAS–P and the SWLS, LSI–Z, SF–36, PIL–SF, and CES–D. Values of <.3, .3 to .6, and >.6 were considered low, moderate, and strong correlations, respectively (Mazaheri et al., 2010).

The discriminative validity of the EMAS–P for age, depression level, and disability level was also investigated. The ability of the EMAS–P to discriminate young (age ≤65 yr) and older (age >65 yr) adults with chronic stroke was studied using independent-samples t tests. On the basis of CES–D scores, participants were also divided into two groups, those with and without depression (CES–D scores of ≥20 and <20, respectively; Agrell & Dehlin, 1989), and EMAS–P scores were compared between the two groups using independent-samples t tests. One-way analysis of variance and post hoc Bonferroni multiple comparisons were used to assess the EMAS–P’s discriminative ability for different disability levels, measured by the mRS. Confirmatory factor analysis was also performed to assess the EMAS–P’s structural validity; results are provided in the Supplemental Appendix, available online with this article at https://research.aota.org/ajot.

A standard multiple regression analysis was done, using demographic and clinical variables (age, gender, marital status, employment, education, time since stroke, number of falls during the past 6 mo, fatigue, depression, pain, cognitive status, and disability level) as independent variables and EMAS–P score as the dependent variable. All the variables were included simultaneously in the regression equation. The significance level was p < .05.

Results

Participant Characteristics

Participants in this study were 123 chronic stroke survivors (75 men, 48 women) with a mean age of 61.26 yr (SD = 12.15). The participants’ mean EMAS–P score was 36.27 (SD = 10.31; range = 17–60). The demographic and clinical characteristics of the participants are provided in Table 1.

Table 1.

Demographic Characteristics of Participants

Characteristic	n (%)	M (SD)
Age, yr		61.26 (12.15)
Gender
Female	75 (61.0)
Male	48 (39.0)
Marital status
Married	96 (78.0)
Single	8 (6.5)
Widowed or divorced	19 (15.5)
Employment status
Jobless	44 (35.8)
Retired	56 (45.5)
Employed	23 (18.7)
Education level
Less than high school	43 (35.0)
High school	50 (40.7)
College	30 (24.3)
No. of mo since onset		27.73 (18.32)
Dominant hand
Right	102 (82.9)
Left	21 (17.1)
Affected side
Right	55 (44.7)
Left	68 (55.3)
Stroke type
Ischemic	104 (84.6)
Hemorrhagic	19 (15.4)
Assistive device for gait
Yes	40 (32.5)
No	83 (67.5)
Falls in past 6 mo
0	60 (48.8)
1–3	12 (9.7)
>3	51 (41.5)
EMAS score at different levels of disability (modified Rankin scale)
No significant disability	32 (26.0)	42.90 (6.62)
Slight disability	37 (30.1)	39.13 (7.91)
Moderate disability	30 (24.4)	33.17 (9.86)
Moderate to severe disability	24 (19.5)	26.92 (10.29)
Height, cm		173.02 (7.44)
Weight, kg		77.73 (9.49)
Fatigue severity (0–10)		4.38 (1.61)
Pain level (0–10)		2.72 (1.83)
Mini-Mental State Examination		26.35 (2.02)

Note. N = 123. EMAS = Engagement in Meaningful Activities Survey.

Reliability

The results showed excellent test–retest reliability (ICC = .87, 95% CI [.77, .93]) among chronic stroke survivors for EMAS–P total score. Ranges for Cohen’s κ coefficient and percentage agreement between test and retest were .37 to .65 and 55% to 74%, respectively, for each EMAS–P item. The EMAS–P’s internal consistency was acceptable (Cronbach’s α = .95). The corrected item–total correlation coefficient was >.500 for all EMAS–P items (Supplemental Table A.1). The SEM, SEM%, MDC, and MDC% were 3.58, 9.8%, 9.92, and 27%, respectively. Floor and ceiling effects were 0% and 2%, respectively.

Validity

Construct Validity

The EMAS–P was strongly and positively correlated with scores on the PIL–SF (r = .86, 95% CI [.76, .96], p < .001), SWLS (r = .83, 95% CI [.72, .94], p < .001), and LSI–Z (r = .75, 95% CI [.62, .88], p < .001), and with scores on the following SF–36 subscales: energy (r = .83, 95% CI [.71, .92], p < .001), physical functioning (r = .73, 95% CI [.61, .86], p < .001), social functioning (r = .72, 95% CI [.58, .85], p < .001), and role limitation due to emotional problems (r = .72, 95% CI [.57, .84], p < .001). There was a moderate positive correlation between EMAS–P score and scores on the following SF–36 subscales: emotional well-being (r = .60, 95% CI [.44, .76], p < .001), general health (r = .58, 95% CI [.42, .74], p < .001), role limitation due to physical health (r = .56, 95% CI [.39, .72], p < .001), and pain (r = .52, 95% CI [.37, .71], p < .001). EMAS–P score was negatively correlated with CES–D scores (r = −.82, 95% CI [−.94, −.71], p < .001), fatigue severity based on VAS–F (r = −.47, 95% CI [−.63, −.31], p < .001), and pain based on VAS–P (r = −.30, 95% CI [−047, −.13], p < .001).

Discriminative Validity

Of the participants in this study, 57% were young adults (age ≤65 yr) with chronic stroke with a mean age of 52.83 yr (SD = 8.63), and 43% were older adults (age >65 yr) with chronic stroke with a mean age of 72.40 yr (SD = 5.04). The mean score on the EMAS–P was 38.64 (SD = 9.40) for young adults and 33.15 (SD = 10.70) for older adults with chronic stroke. There was a significant difference between the two groups for EMAS–P score, t(121) = 3.02, 95% CI [1.9, 9.1], p = .003.

Thirty-four percent of the participants had depression (CES–D score ≥20). The mean EMAS–P score was 25.02 (SD = 7.31) for stroke survivors with depression and 41.63 (SD = 7.49) for those without depression. EMAS–P scores were significantly different between stroke survivors with and without depression, t(121) = 10.58, 95% CI [13.5, 19.7], p < .001.

EMAS–P scores were significantly different among stroke survivors with different levels of disability (see Table 1), F(3, 119) = 18.35, p < .001. The results of multiple comparisons of EMAS–P score showed a significant difference in all comparisons, except for that between no disability and low disability. Stroke survivors with a higher level of disability obtained significantly lower scores on the EMAS–P (r = −.56, 95% CI [−.68, −.41], p < .001).

Multiple Regression Model

A standard multiple regression analysis was done to predict EMAS–P scores using the demographic and clinical variables. All of the variables were included simultaneously, and the tested model reached significance, F(11, 111) = 27.16, p < .001, accounting for 79% of the variance in EMAS–P score as a whole. The results indicated that depression level, disability level, fatigue severity, and gender were significant predictors of EMAS–P score (p < .05) and uniquely accounted for 19.97%, 2.99%, 2.25%, and 1.77% of the variance in the EMAS–P score, respectively (Supplemental Table A.2).

Discussion

To the best of our knowledge, this is the first study to translate the EMAS into Persian and investigate its reliability and validity among chronic stroke survivors. The results of the current study showed that the EMAS–P has good internal consistency. Good to excellent internal consistency (Cronbach’s αs = .81–.91) has also been reported for the original, Spanish, Polish, and French versions of the EMAS (Brożek & Tokarz, 2017; Eakman et al., 2010; Goldberg et al., 2002; Lacroix et al., 2018; Prat et al., 2019). In line with previous studies (Prat et al., 2019), the results of this study also showed excellent test–retest reliability of the EMAS–P among chronic stroke survivors. However, Goldberg et al. (2002) reported moderate test–retest reliability (r = .69) for the original version of the EMAS and suggested that its test–retest reliability should be reassessed because of the long interval between test and retest (2–10 wk) in their study. The SEM of the EMAS–P was 3.5, which was lower than the acceptable criterion (SEM < SD/2) and indicates that the EMAS–P has sufficient accuracy for the evaluation of chronic stroke survivors. The MDC of the EMAS–P was 9.92, which shows that changes higher than this value should be considered as indicating real improvement in participation in meaningful activity (Lin et al., 2010). No significant ceiling or floor effect was found among chronic stroke survivors.

Construct validity is the extent to which a scale measures the concept it is supposed to measure. We evaluated the construct validity of the EMAS–P by investigating its correlation with the SWLS, LSI–Z, SF–36, PIL–SF, and CES–D. In line with previous studies of older adults and people with severe mental illness (Eakman et al., 2010; Goldberg et al., 2002), the results showed a strong positive correlation between EMAS–P score and life satisfaction as measured with the SWLS and LSI–Z. Decreased participation in meaningful activities is usually observed among chronic stroke survivors as a result of disability, which is associated with decreased life satisfaction (McKenna et al., 2009).

The results of the current study showed a positive correlation between all subscales of the SF–36, a measure of quality of life, and EMAS–P score, which can be explained by the fact that the meaningfulness of the activities can contribute to a high quality of life (Goldberg et al., 2002). A strong positive correlation was also found between the EMAS–P and life purpose as measured with the PIL–SF. This significant correlation has also been reported for older adults and people with severe mental illness (Brożek & Tokarz, 2017; Eakman et al., 2010).

The results of this study also revealed a strong negative correlation between EMAS–P score and depression level as measured with the CES–D. One possible explanation for this negative correlation may be that the EMAS–P assesses people’s experiences of engagement in different activities, and depression may negatively affect the interpretation of these experiences (Beck, 2008). However, Eakman et al. (2010) reported a low negative correlation between the EMAS and depression level among older adults. This discrepancy can be explained by the fact that the prevalence of depression among older adults is lower than that among stroke survivors (Hornsten et al., 2012).

The results of this study showed that the EMAS–P had good discriminative validity for age, depression, and disability level among chronic stroke survivors. Older adults had lower EMAS–P scores than young adults, as did chronic stroke survivors with depression compared with those without depression. Moreover, the results indicated that EMAS–P score had a good ability to discriminate among chronic stroke survivors with different levels of disability.

The results of a multiple regression analysis indicated that depression, disability level, fatigue, and gender were significant predictors of EMAS–P score among chronic stroke survivors. Among the different factors, depression was the strongest predictor of EMAS–P score, confirming the importance of assessing and treating depression to increase the level of engagement in meaningful activities among these patients (Desrosiers et al., 2006). A high level of disability is associated with increased limitations in mobility and inability to complete essential activities in the desired way (Fallahpour et al., 2011), leading to change in the subjective experience of engagement (Williams & Murray, 2013).

Female gender was another predictor of EMAS–P score among chronic stroke survivors. A possible explanation may be that women experienced more severe stroke and, thus, worse functional outcomes (Ezekiel et al., 2019; Phan et al., 2018), as well as the greater value placed on body image by women, leading to changes in the sense of engagement among women with stroke (Chau et al., 2009). Contextual factors (e.g., culture-induced barriers to participation in activities faced by Iranian women; Alami & Delshad Noghabi, 2016) may also be involved in this finding. Fatigue was also a predictor of EMAS–P score. It has been suggested that fatigue may increase subjective physical effort to perform activities, leading to increased risk of role restrictions and loss, increased sleep time and, finally, changes in the sense of engagement in meaningful activities among chronic stroke survivors (White et al., 2012). We should note that cognitive function was not associated with EMAS–P score in this study, which may be because only stroke survivors with adequate cognitive function were included.

Limitations

The current study was limited by a nonprobability sampling method. Moreover, cognitive screening of the participants was done using the Mini-Mental State Examination (MMSE; Folstein et al., 1975), one of the most widely used tools in clinical settings to diagnose global cognitive impairment among stroke survivors (Delavaran et al., 2017). However, MMSE scores reflect domain-general cognitive dysfunction, not poststroke domain-specific cognitive dysfunction. Also, the study did not include stroke survivors with aphasia or cognitive impairment. Moreover, other factors not included in the design, such as personality traits, may also affect engagement in meaningful activities. Finally, we did not investigate the reliability and validity of the EMAS–P by gender and lesion side.

Implications for Occupational Therapy Research and Practice

The findings of this study suggest some important implications for occupational therapy research and practice:

The EMAS–P is a reliable and valid assessment tool that can be used by occupational therapists to evaluate the engagement of community-dwelling chronic stroke survivors in meaningful activities in the Iranian context.

The EMAS–P accurately differentiates disability and depression levels among Iranian chronic stroke survivors.

Depression, disability, and fatigue level predict the extent of participation in meaningful activities, especially among Iranian women with chronic stroke. Thus, we recommend that these factors be considered in designing occupational therapy interventions to improve the engagement of these patients, particularly women, in meaningful activities.

Conclusion

The results of this study indicate that the EMAS–P is a reliable and valid measure of participation in meaningful activities among chronic stroke survivors in the sample tested, supporting its clinical application for measuring changes in these patients’ engagement in meaningful activities after rehabilitation interventions. The results also reveal that depression, disability level, fatigue, and gender were significant predictors of EMAS–P score among chronic stroke survivors who participated in this study. Moreover, the EMAS–P showed a good ability to differentiate among chronic stroke survivors of different ages and with different levels of depression and disability.

Supplemental Material

Supplemental Information

Supplementary material for Validation of the Persian Version of the Engagement in Meaningful Activities Survey (EMAS) in an Iranian Stroke Population: Predictors of Participation in Meaningful Activities

Supplementary material, sj-pdf-1-aot-10.5014_ajot.2022.046623.pdf for Validation of the Persian Version of the Engagement in Meaningful Activities Survey (EMAS) in an Iranian Stroke Population: Predictors of Participation in Meaningful Activities by Moslem Cheraghifard, Malahat Akbarfahimi, Akram Azad, Aaron M. Eakman and Ghorban Taghizadeh in The American Journal of Occupational Therapy

Footnotes

Acknowledgments

This study was supported by the Iran University of Medical Sciences, Tehran.

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