Benefits of Daily Occupational Diary Use 3 Months After a Health Promotion Program for Community-Dwelling Older Adults

Study Design

This study was conducted after the RCT conducted by our team (Takagi, Goami, Orita, & Bontje, 2020). Most control group participants received the program immediately after the RCT was conducted. A before-and-after comparison study verified the relationship between receipt of the program and changes in satisfaction with occupation, a sense that life is worth living, and life satisfaction. A case–control study was also conducted to clarify the factors associated with changes in satisfaction with occupation after the program.

Participants

The selection criteria for participants were (1) age ≥65 yr, (2) living independently, and (3) being able to answer the questionnaire on their own. Exclusion criteria were living in a care facility or being hospitalized.

Participants were recruited from a city in Japan with a population of just under 100,000 and an aging rate of 34.5% as of 2019; the population ages and declines annually. All older adults living in the city were approached through a public relations magazine and flyers distributed throughout the city. We gathered 152 people interested in the program in a university classroom to explain the study outline; 144 people agreed to participate.

Program

The Conceptual Model of Self-Monitoring (Wilde & Garvin, 2007) and Social Cognitive Theory (Bandura, 1986, 2004) were applied to the program to improve participants’ ability to manage daily occupations. We expected that occupational experiences that made participants feel satisfied with their daily lives would increase if participants improved their ability to manage daily occupations. Hence, we hypothesized that an increase in participants’ positive occupational experiences would be related to their improved satisfaction with occupation, enhanced sense that life is worth living, and increased life satisfaction (Takagi, Goami, & Bontje, 2020; Takagi, Goami, Orita, & Bontje, 2020).

This program consisted of using an occupational diary and attending group sessions. Participants were expected to use the diary at home daily during the program. Each day, participants selected the activity they did that day that most influenced their daily satisfaction. Next, they chose which elements (connection, affirmation, contribution, effort, enjoyment, progress, success, acquisition, and recovery; Takagi et al., 2019) fit their occupational experience. Figure 1 shows how the diary was completed and provides examples.

OPEN IN VIEWER

Figure 1.

Instructions for writing an entry in the occupational diary and an example of a diary entry.

Group sessions were held once per week for 4 wk. Each session lasted 2 hr. The sessions included three elements: (1) lectures that provided the knowledge necessary to understand the relationship between daily occupational experiences and life satisfaction, (2) exercises in which participants analyzed their daily experiences on the basis of occupational diary and planned their daily occupations, and (3) sharing the plans that were made and the results of executing those plans. Specifically, in the first session, participants learned the relationship between occupation and satisfaction, as well as how to keep an occupational diary. They were then asked to make daily diary entries. In the second and subsequent sessions, they analyzed the past week’s diary entries and planned an occupation that could be performed the next week. Finally, the plan was shared with the group members. Carrying out the plan and keeping the diary were homework. At the beginning of each session, group members reflected on and shared the results of executing their plans. All group sessions were held in a classroom at the university. The first author, Masayuki Takagi, an occupational therapist, conducted all sessions, including lectures, exercises, and sharing, and the second author, Naruko Goami, also an occupational therapist, assisted.

The program was implemented over two terms: from January to February 2019 and from February to March 2019. Sixty-two participants attended the first term, and 82 participants attended the second. In both terms, participants were divided into four groups of 15 to 22 people according to their schedule. Each group’s participants attended the sessions at the same time. At the end of the program, an additional diary was distributed to all participants so that they could continue to write for 3 mo after the program. The decision to continue using the diary after the program was left to their discretion.

Outcome Variables and Measures

Evaluations were conducted at the start of the program (pretest), at the end of the program (posttest), and at the follow-up held 3 mo after the program. The first author who conducted the group sessions also distributed and collected the questionnaires in a university classroom during all evaluations. Participant characteristics were collected, including sex, age, educational background, family status, income, whether they drove a car, hobbies, diary habits, medication, hospital visits, going out, interacting with friends, and perceived health at the pretest.

Each evaluation measured satisfaction with occupation, a sense that life is worth living, and life satisfaction. Satisfaction with occupation was the primary outcome. The ADLSS (Okamoto, 2009) was used to measure satisfaction with occupation. The respondents rated four items on a 5-point scale ranging from 1 (not applicable at all) to 5 (very applicable). Cronbach’s coefficient α was .83, and coefficient ω was .86 (Okamoto, 2009).

The K–I (Kondo & Kamada, 2003) was used to measure the sense that life is worth living. The respondents rated 16 items on a 3-point scale (0 = no; 1 = not sure; 2 = right), with total scores ranging from 0 to 32; higher scores indicated a higher sense that life is worth living. The correlation coefficient was .87, and the test–retest correlation coefficient ρ was .83. Cronbach’s coefficient α was .82 (Kondo & Kamada, 2003).

The LSI–Z (Wood et al., 1969) was used to measure life satisfaction. The respondents rated 13 items on a scale ranging from 0 to 2. Total scores could range from 0 to 26; higher scores indicated higher satisfaction. The correlation coefficient was .57, and the Kuder– Richardson 20 coefficient α was .79 (Wood et al., 1969). Participants’ scores on the LSI–Z showed significant changes as a result of the effects of Lifestyle Redesign (Clark et al., 1997, 2012) and a program that applied the Model of Human Occupation (Yamada et al., 2010).

The continued use of the diary was evaluated only at follow-up. A self-administered questionnaire was used to investigate whether the participants continued to use the diary after the program ended. Participants were asked, “Have you written in the occupational diary since the program cessation?” Response options were “I have written in it every day,” “I have sometimes written in it,” “I don’t keep one,” or “other.” We rated “I have written in it every day” and “I have sometimes written in it” as “continued use”; “I don’t keep one” was rated as “no continued use,” and “other” responses were assigned to either category on the basis of the reasons given.

Statistical Analyses

To examine the relationship between the program and changes in scores 3 mo after the end of the program, we compared scores on each scale at pretest, posttest, and follow-up, using the Friedman test because normality could not be confirmed using the Lilliefors test. Next, multiple comparisons were performed using the Wilcoxon signed-rank test (with Bonferroni correction) for the variables that showed significant differences. The effect size r was calculated from the Z value of the Wilcoxon signed-rank test. We considered r = .10 a small effect, r = .30 a medium effect, and r = .50 a large effect (Cohen, 1988).

To examine the factors associated with changes in satisfaction with occupation after the program, those whose ADLSS score improved or did not change at follow-up in comparison with their score at posttest were designated the maintenance/improvement group; those whose score declined were designated the decline group. Next, we conducted between-groups comparisons of participant characteristics, score on each scale at posttest, and continued use of the diary using the t test, Mann–Whitney U test, and χ² test. Univariate logistic regression analysis was performed with the two groups—maintenance/improvement and decline—as the dependent variables to determine the independent variables. For the result, the variables with p < .10 were collected as independent variables, and a multivariate logistic regression analysis was performed with the two groups as the dependent variables (Uchida, 2016). IBM SPSS Statistics (Version 23) was used for the statistical analyses, and the significance level was set to p < .05.

Ethical Considerations

This study was conducted with the approval of the research ethics committee of the Prefectural University of Hiroshima (18MH028).

Participant Characteristics, Program Attendance, and Continued Use of the Occupational Diary

Of the 144 participants, 3 declined to participate in the program because of difficulty adjusting to the schedule or poor health and were not evaluated at posttest. In addition, 4 participants were absent from the follow-up because of poor health. Data from the 137 participants who completed all three evaluations were analyzed (follow-up rate = 95.1%). The participants’ mean age was 72.5 yr (SD = 5.69); 104 participants (75.9%) were women; 133 participants (97.1%) attended all four sessions; the remainder attended three sessions. At the follow-up, 69 (50.4%) participants’ use of the diary was rated as “continued use,” and 68 (49.6%) participants’ use was rated as “no continued use” (Table 1).

Change in Scores at 3-Mo Follow-Up

The ADLSS score at follow-up (Mdn = 16, interquartile range [IQR] = 15–19) was significantly higher than at pretest (Mdn = 16, IQR = 14–18; p = .005, Z = −3.14), but the effect size was small (r = .19, 95% confidence interval [CI] [0.07, 0.30]; Table 2). The K–I score at follow-up (Mdn = 28, IQR = 23–30) was significantly higher than at pretest (Mdn = 25, IQR = 20–29; p < .001, Z = −4.26), but the effect size was small (r = .26, 95% CI [0.14, 0.36]). The LSI–Z score at follow-up (Mdn = 19, IQR = 16–22) was significantly higher than at pretest (Mdn = 17, IQR = 14–21; p < .001, Z = −5.26), and the effect size was medium (r = .32, 95% CI [0.21, 0.42]).

Factors Related to Changes in Satisfaction With Occupation After the Program

Comparison of the two groups—maintenance/improvement and decline—showed that the continued use of the occupational diary was significant at p = .05, χ²(1) = 0.03 (see Table 1). The univariate logistic regression analysis showed that continued use of the diary and posttest ADLSS score were significant at p < .10. Therefore, multivariate logistic regression analysis was performed with continued use of the diary and the posttest ADLSS score as independent variables; the dependent variables were the two groups. Only continued use of the diary was shown to be a factor related to changes in ADLSS score after the program. The results of the model’s χ² test were significant, χ²(1) = 4.60, p = .03. The odds ratio for continued use of the diary was 2.10 (95% CI [1.06, 4.17], B = 0.742, SE = 0.35, p = .03).

Considerations

In this study, ADLSS, K–I, and LSI–Z scores at the 3-mo follow-up were significantly higher than those at pretest, with small to medium effects. This suggests that the health promotion program was related to improved satisfaction with occupation and subjective well-being among community-dwelling older adults 3 mo after program cessation.

Occupational literacy encourages people to view their daily lives from an occupational perspective and to talk, write, and think about their daily occupations (Townsend, 2015). In this program, participants applied the acquired occupational knowledge to their daily lives and recorded and shared their experiences with others from an occupational perspective. Participants’ experience of these processes increased their occupational literacy and promoted their participation in daily occupations, even after the program was completed.

At follow-up, about half of the participants continued to use the diary. Continued use of the diary was selected as the analysis result for the factor related to changes in satisfaction with occupation after the health promotion program. Therefore, continued use of the occupational diary likely allowed for the level of satisfaction with daily occupations to be maintained and improved beyond the program period.

The diary was devised for participants to record the positive aspects of their daily occupations that brought them feelings of satisfaction. Subjective well-being is enhanced by observing and recording positive aspects of daily life (Seligman et al., 2005). The use of the occupational diary, which focused on the positive aspects of occupation, may have had positive effects on the sense that life is worth living and life satisfaction after the program.

Research Limitations

This study did not include a control group; thus, the influences of factors other than the program cannot be ruled out. The follow-up period was shorter than in previous studies (Clark et al., 2001; Kawamata et al., 2014; Zingmark et al., 2014). Therefore, a future study that includes a control group is needed to verify the longer term effects of the program.

Participants in this study were older adults living in an local city with a population of just less than 100,000. Many of the participants may have had a high intrinsic motivation to learn, and they tended to have obtained the study information from a public relations magazine or flyers. Thus, the relationship between the health promotion program and community-dwelling older adults’ satisfaction with occupation, sense that life is worth living, and life satisfaction after cessation may change depending on their area of residence or intrinsic motivation to learn.

Although those who answered “I have written in the diary every day” or “I have sometimes written in it” were rated as “continued use” to identify factors associated with changes in satisfaction with occupation after the program, we did not evaluate how frequently they wrote. Therefore, further research is needed to investigate the relationship between the frequency of diary use and changes in satisfaction with occupation.