Psychometric Properties of the Spanish Version of the Satisfaction With Daily Occupations and Occupational Balance in Spanish Stroke Survivors

Abstract

Importance: Stroke survivors experience changes in participation level, satisfaction with participation, and participation balance, making it necessary to have a validated tool for their assessment.

Objective: To evaluate the psychometric properties of the Spanish version of the Satisfaction With Daily Occupations and Occupational Balance (SDO–OB) in stroke survivors.

Design: Psychometric study.

Setting: National multicenter study (rehabilitation centers, and hospitals).

Participants: One hundred forty stroke survivors with and without a primary caregiver.

Outcomes and Measures: Participants completed the SDO–OB, the five-level version of the EQ–5D (EQ–5D–5L), and the Activity Card Sort (ACS). Internal consistency, convergent validity, known-groups validity, and floor and ceiling effects were assessed. Intraobserver reliability was assessed 1 wk apart.

Results: The internal consistency was acceptable; Cronbach’s α = .80, 95% confidence interval (CI) [0.75, 0.85]. A moderate correlation was found between the SDO–OB summed participation level and summed participation satisfaction (ρ = .53). Both SDO–OB summed scores correlated with ACS scores (0.25 < ρ < .61). However, only summed participation satisfaction scores correlated with the emotional component of the EQ–5D–5L (ρ = .32). The SDO–OB discriminated between groups with and without a caregiver (p = .001) and had no floor or ceiling effects (<7%). Good intraclass correlation coefficients (ICCs) were obtained for summed participation level (ICC = .91; 95% CI [.85, .94]) and summed participation satisfaction (ICC = .86; 95% CI [.78, .92]). Standard error of measurement and minimum detectable change were 0.7 and 1.9 points, respectively, for summed participation level and 4.5 and 12.4, respectively, for summed participation satisfaction.

Conclusions: The Spanish version of the SDO–OB presented good psychometric properties, making it a suitable instrument to address participation level, participation satisfaction, and participation balance in stroke survivors.

Plain-Language Summary: After a stroke, survivors experience changes in their participation in daily activities and how satisfied they are with them. This study examined whether a tool called Satisfaction With Daily Occupations and Occupational Balance (SDO–OB) could provide reliable information about this. We looked at 140 stroke survivors from different places in Spain to see whether they had someone caring for them, how healthy they were, and how their participation in daily activities changed after stroke. We found that the SDO–OB is helpful for understanding a stroke survivor’s situation and can identify areas needing intervention and track changes caused by intervention plans.

The Spanish version of the Satisfaction With Daily Occupations and Occupational Balance intervention presented good psychometric properties, making it a suitable instrument to address participation level, satisfaction, and balance in stroke survivors.

A stroke is a cerebrovascular disease that is the third leading cause of disability in the world. In 2019, Spain had an incidence of 61,102 cases of people with poststroke sequelae (GBD 2019 Stroke Collaborators, 2021). According to World Health Organization (WHO) projections, one in four people will have a stroke throughout their lifetime (GBD 2019 Stroke Collaborators, 2021), leaving sequelae that will generate limitations in daily activities and restrictions in participation for that person (Norlander et al., 2016) and will cause a high cost that will become necessary to reduce through rehabilitation (Della Vecchia et al., 2021).

Previous studies have indicated that social support plays a significant role in predicting community participation among stroke survivors, although stroke survivors face various barriers, including social stigma and their own personal attitudes, which can lead to increased isolation (Elloker & Rhoda, 2018; Shrivastav et al., 2022). However, a high percentage of stroke survivors live at home with substantial support from family members and/or privately employed assistants. Many of these caregivers take on the role of providing assistance when the person is unable to participate on their own. Moreover, some stroke survivors may increase their self-confidence with the help of others, which is necessary to overcome environmental barriers (Bailey, 2019). Despite these factors, the relationship between participation in activities and the presence of a primary caregiver remains underexamined (Hall et al., 2020).

Participation is essential for stroke survivors’ well-being and quality of life (Norlander et al., 2018). The term participation is included in the International Classification of Functioning, Disability and Health (ICF) and, together with the term activity, consists of nine domains: learning and applying knowledge, general tasks and demands, communication, mobility, self-care, domestic life, interpersonal interactions and relationships, major life areas and community, and social and civic life (WHO, 2001). It is a comprehensive concept including various facets such as the range of activity areas in which a person participates, perceived balance in participation, and satisfaction with participation (American Occupational Therapy Association, 2020). It has been observed that participation restrictions involve an important change in the participation balance and satisfaction of stroke survivors (Kassberg et al., 2021; Wagman et al., 2012), and this can lead to participation imbalance (Kassberg et al., 2021).

Adequate assessment tools are crucial for understanding the adjustment process in relation to the participation level, the satisfaction with participation, and the participation balance that occurs through giving up previous participation in activities or incorporating participation in new ones poststroke. Using such tools provides important information about the person’s lifestyle and their perception of it, enabling the detection of motivation or resistance to potential changes in their current participation situation. Among the assessment tools that exist in Spanish, those that are most used with this group typically measure activities of daily living, but they do not include satisfaction or the sense of balance that these activities may generate (Tse et al., 2013). Moreover, assessments are often used without considering their psychometric properties, such as adaptation to the Spanish context or their validity for a specific population (Prieto- Botella et al., 2022). Specifically, the participation domain of the Stroke Impact Scale (SIS–P; Mulder et al., 2016), the Assessment of Life Habits Scale (Engel-Yeger et al., 2018) and the Activity Card Sort (ACS; Ezekiel et al., 2019) are the most commonly used participation assessment tools for stroke survivors under the ICF framework. However, they do not uniformly cover the nine activity and participation domains of the ICF, leading to biased information (Ezekiel et al., 2019), and they may not fully capture the perceived impact of stroke on these domains (Ytterberg et al., 2017). The SIS–P is the only one validated for Spanish stroke survivors (Aguado, 2010).

At present, there is a need for an assessment instrument in Spanish that is validated for stroke survivors and assesses participation level in the broad sense that is operationalized in the ICF framework and additionally addresses satisfaction with participation and participation balance (Palstam et al., 2019; Wassenius et al., 2022). One such instrument is the Satisfaction with Daily Occupations and Occupational Balance (SDO–OB; Eklund & Argentzell, 2016). This tool provides a subjective and individualized view of the person regarding restrictions in participation, which is necessary for person-centered health practice (Ezekiel et al., 2019).

The Satisfaction with Daily Occupations (SDO) is a tool that was constructed with the aim of assessing a person’s participation level and satisfaction according to four participation areas: work, leisure, home management, and self-care. The SDO was later extended to the SDO–OB, with questions on participation balance for each participation area (Eklund & Argentzell, 2016). In the SDO–OB, participation balance refers to the person’s perception of having the right amount and the right variation of activities (Wagman et al., 2012). The SDO was initially validated in various populations with mental health problems in Sweden (Eklund, 2004; Eklund & Gunnarsson, 2008; Eklund & Sandqvist, 2006), but it was also used successfully with people who had been diagnosed with Parkinson’s disease (Hultqvist et al., 2020). An Arabic version of the SDO has been validated in a population with neurological conditions, the majority of whom were stroke survivors (Manee et al., 2015), and a Danish version has been validated in a population of asylum seekers (Eklund & Morville, 2014). Furthermore, the SDO–OB was translated and cross-culturally adapted for the Spanish population through a forward- and back-translation process and was subsequently validated in a Spanish population with mental health problems (Vidaña-Moya et al., 2020). However, the Spanish version has not yet been validated for stroke survivors.

Given that there is no validated Spanish assessment tool for a population of stroke survivors that fully covers the domain of participation in activities (Tse et al., 2013), including the person’s own perspective, developing such tools is an urgent matter (Engel-Yeger et al., 2018). The Spanish version of the SDO–OB (Vidaña-Moya et al., 2020), validated for people with mental illness and those without a known illness, might also be an appropriate tool for stroke survivors. It could provide key data for stroke survivors concerning participation level and satisfaction with participation, and it could give a time allocation perspective on their perceived participation balance. Such information would be vital for setting goals, developing individualized treatment plans, and evaluating results; and, if found psychometrically sound with stroke survivors, the Spanish version of SDO–OB could be used in both clinical practice and research.

In the present study, we aimed to evaluate the psychometric properties (internal consistency, convergent validity, known-group validity, floor and ceiling effects, intraobserver reliability, and measurement error) of the Spanish version of the SDO–OB when used with people who had a stroke more than 6 mo earlier.

Method

This psychometric study was conducted between February and November 2022 as part of the Part&Sed-Stroke project (de Diego-Alonso et al., 2023). It is a multicenter research project focused on a multidimensional analysis of sedentary behavior and participation among Spanish stroke survivors who were followed for up 6 mo after onset, involving 20 collaborating centers throughout Spain. The study was approved by the regional ethics committee on human research (PI21/333), and all participants provided informed consent before enrolling.

Participants

Spanish stroke survivors who were followed up after 6 mo were recruited from several rehabilitation centers, clinics, and hospitals participating in the Part&Sed-Stroke project. In each center, collaborators (physiotherapists and occupational therapists) promoted the research study by means of information sheets. Candidates who met the selection criteria signed the informed consent form. The inclusion criteria were as follows:

▪ ages 18 yr and older;

▪ a history of diagnosed stroke for more than 6 mo, regardless of etiology;

▪ outpatient living at home;

▪ cognitive and speech ability to complete the pertinent tests and understand the purpose of the research (i.e., no aphasia and a Mini-Mental Cognitive Test score higher than 24; Lobo et al., 1999), double-checked by collaborators and the principal investigator); and

▪ the ability to use and availability of a mobile phone.

The three exclusion criteria were

▪ the presence of alterations in comprehension or expression that significantly interfered with data collection,

▪ residence in institutions (e.g., nursing homes), and

▪ no commitment to continue with the study.

The sample size was determined on the basis of the recommended ratio of a minimum of 10 to 15 subjects per the number of items in the questionnaire (Anthoine et al., 2014). Missing values of approximately 5% were assumed. Therefore, 140 participants were required.

Sociodemographic and Clinical Data

Sociodemographic data included age, sex, educational level, family situation, and the presence or absence of a principal caregiver. A principal caregiver was defined as a person, either a family member or privately employed assistant, who spends more than half of their daily time supporting or caring for the stroke survivor.

Clinical data included the date of stroke; type of stroke; damaged cerebral hemisphere; and the Barthel Index, a scale that measures the level of independence in activities of daily living and is one of the most widely used outcome measures to assess functioning in the context of neurorehabilitation (Prodinger et al., 2017).

Outcome Measures

Health Status

The five-level version of the self-assessed quality of life questionnaire EQ–5D (EQ–5D–5L) was used to assess current health status. Respondents rate their quality of life in relation to mobility, self-care, usual activities, pain and discomfort, and anxiety or depression through five possible response options ranging from 1 (no limitations or disability) to 5 (maximal limitations or disability). In the second part of the questionnaire, respondents indicate their current health status on a scale ranging from 0 (worst health status imaginable) to 100 (best health status imaginable). The EQ–5D–5L is a valid and reliable tool for assessing health-related quality of life (Ramos-Goñi et al., 2013), it is also used for people who have had a stroke less than 6 mo previously, and it has been used previously in other studies (de Graaf et al., 2022; Golicki et al., 2015).

Regarding the convergent validity hypothesis, it was expected that participants with higher levels of participation and total satisfaction in the SDO–OB would score higher on perceived level of health (or lower limitations or disability, in the case of the subscales), especially on those items that are directly related to participation in daily activities (Norlander et al., 2018).

Perception of Changes in Participation Level

We used the Spanish version of the ACS to assess changes in participation. Of the nine domains defined by the ICF (WHO, 2001), the ACS covers eight, further compiled into four participation areas encompassing 20 instrumental activities, 35 leisure activities with low physical demand, 17 leisure activities with high physical demand, and 17 social activities. Photographs (i.e., cards) reflecting these daily activities were shown to the respondents, who indicated whether they participated in the activities before the onset of their illness. After viewing the photographs that depicted daily activities, respondents indicated whether they currently maintained their participation at the same level, decreased their participation, or stopped participating altogether. The final score, expressed as a percentage, combines the four participation areas, reveals the overall level of engagement in activities, and shows whether there have been any discontinuations in participation. The ACS is a reliable and validated tool for measuring the perceived level of participation in a Spanish population (Alegre-Muelas et al., 2019), and it has been used previously in stroke survivors after the first 6 mo (Hartman-Maeir et al., 2007).

Regarding the convergent validity hypothesis, it was expected that participants with higher total participation levels according to the SDO–OB would have higher percentages of maintained participation, indicating less change after stroke according to the ACS. Finding such a correlation with the total sum of satisfaction with participation was, however, not expected, because people with low levels of participation may present high levels of satisfaction that are due to resilience and a process of acceptance of the new situation after stroke (Sarre et al., 2014).

Participation Level, Degree of Satisfaction With Participation, and Participation Balance

Participation level, degree of satisfaction with participation, and participation balance among activities were assessed with the Spanish version of the SDO–OB (Vidaña-Moya et al., 2020), an interview-based instrument addressing 13 different everyday activities, organized into four areas: work, leisure, home management, and self-care. With a structured interview format, the SDO–OB is used to assess the level of participation, the satisfaction derived from engaging in this participation, and the perceived participation balance, including the perceived time allocation (if you do too little, just enough, or too much) within each area. For each item, the respondent indicates whether they have recently participated or not (yes–no) and provides a self-rating in relation to the degree of satisfaction with that situation ranging from 1 (being extremely dissatisfied) to 7 (being extremely satisfied). Yes responses were summed into a participation level score, and the satisfaction ratings were summed to form the satisfaction with participation score. The participation balance scores were rated for each area to assess whether the respondent performed enough, too much, or too little of the activities belonging to that area. Five responses were considered: way too little (–2), too little (–1), just enough (0), too much (1), and way too much (2) (Vidaña-Moya et al., 2020). The SDO–OB also included an overall item regarding general participation balance that uses the same response alternatives. Furthermore, following previous recommendations (Eklund & Argentzell, 2016), we grouped the scores for further analysis as underoccupied (score = –2 or –1), in balance (score = 0), and overoccupied (score = 1 or 2).

Procedure

Before data collection, we conducted a pilot study with 10 stroke patients and 10 professional collaborators. To assess content validity, we interviewed stroke survivors and professional collaborators on the clarity and comprehension of each SDO–OB question and answer type. There were no documented concerns or challenges with the clarity and comprehension of the questions and type of responses of the scale.

During data collection, all participants answered questions on sociodemographic information, clinical history, Barthel Index, the EQ–5D–5L, and the ACS. Participants were classified for further analysis according to the presence of a principal caregiver. Furthermore, according to COSMIN criteria (Mokkink et al., 2010), which considers 50 to 99 participants as an adequate sample for reliability calculations, a subset of 70 participants was randomly selected to complete the Spanish version of the SDO-OB again 1 wk later with the same assessor to analyze intraobserver reliability.

Two circumstances warranted that face-to-face interviews were chosen for the data collection. First, some of the instruments used to collect data, such as the ACS and the SDO–OB, require this. Second, a large number of variables were collected in the Part&Sed-Stroke project. Face-to-face interviews allowed for monitoring the participants; splitting the data collection on several occasions, if necessary; and, thus, avoiding saturating them or losing their concentration. In contrast, clinical data and scores based on the Spanish version of the SDO–OB were collected by a single-blind evaluator who was trained in the administration of the Spanish version of the SDO–OB, with no clinical link to the participants to avoid intraobserver bias (Cristina de Diego-Alonso, an occupational therapist and physiotherapist with 15 yr of experience in treating neurological patients) by videoconference. Collaborators were supervised by the research team and shared the data collected through an encrypted data application (Bellosta-López et al., 2021).

Statistical Analysis

Data distribution was assessed using the Kolmogorov– Smirnov test. Quantitative variables were expressed as median and interquartile range (IQR) or mean and standard deviation (SD), depending on the data distribution. Categorical variables were expressed as numbers and percentages.

The internal consistency of the Spanish version of the SDO–OB satisfaction items was assessed with the Cronbach’s α and corrected item–total correlations (CITCs). A Cronbach’s α higher than .7 (Tavakol & Dennick, 2011) and a CITC higher than .3 (Terwee et al., 2007) were considered acceptable.

Convergent validity was assessed with the Spearman’s rank correlation. Correlations were calculated between the summed scores of the Spanish version of the SDO–OB (i.e., participation level and satisfaction level, respectively) and the EQ–5D–5L, ACS, and a question (general satisfaction with daily activities) used in the original Spanish validation (Vidaña-Moya et al., 2020). Correlations were considered as strong (ρ ≥ .70), moderate (.40 > ρ < .69), weak (.10 > ρ < .39), or negligible (ρ < .10; Akoglu, 2018).

We assessed known-groups validity for the summed scores by using the Mann–Whitney U test to compare participants who received daily support from a principal caregiver with those who did not. In addition, χ² tests were used to compare the participation balance scores.

The test–retest reliability of the Spanish version of the SDO–OB summed scores (i.e., participation level and satisfaction level) was assessed for single measurement absolute agreement, on the basis of a two-way random model, by computing intraclass correlation coefficients (ICCs_2,1). ICCs above .90 were considered excellent; ICCs of 0.75 to .90, good; ICCs of .50 to .75, moderate; and ICCs less than .50, poor reliability (Koo & Li, 2016).

We calculated the standard error of measurement (SEM) and the minimum detectable change (MDC) at 95%. The SEM—representing the expected random score variation when no real change has happened in a single person—was calculated with the following formula: SEM = SDpooled × √(1 − ICC) (Furlan & Sterr, 2018). The MDC—representing the minimal change needed for being a real change rather than a random measurement error in a sample—was calculated with the following formula: MDC = SEM × √2 × 1.96 (Furlan & Sterr, 2018). For the participation balance scores, the overall rate of agreement was calculated, and the weighted κ correlation coefficient was used to assess item response stability after 1 wk. The association was defined as very good (.81 ≤ κ ≤ 1.0), good (.61 ≤ κ ≤ .80), moderate (.41 ≤ κ ≤ .60), fair (.21 ≤ κ ≤ .40), or poor (.00 ≤ κ ≤ .20; Cohen, 1960).

Fewer than 15% of the respondents achieving the lowest or highest scores were set as criteria for an absence of floor or ceiling effects, respectively (Terwee et al., 2007).

Statistical analysis was performed using IBM SPSS Statistics (Version 28), and statistical significance was accepted at p < .05.

Results

Participant Characteristics

Of the 140 participants recruited for the study, 128 provided full data and were included in the analysis. A total of 68 out of the 70 participants who were randomly selected to assess the test–retest reliability completed the Spanish version of the SDO–OB a second time 1 wk after analysis (M = 7.2, SD = 0.2 days). Sociodemographic and clinical characteristics are presented in Table 1.

Table 1.

Sociodemographic and Clinical Data of Participants

Sociodemographic Variables	n (%)
Age (yr), M (SD)	61.8 (12.4)
Female	47 (37)
Living alone	19 (15)
Principal caregiver	68 (53)
Study level
No schooling	3 (2)
Primary studies	27 (21)
Secondary studies	54 (42)
University studies	44 (34)
Time since stroke (yr), Mdn (IQR)	3.5 (1.7–7.0)
Stroke type
Hemorrhagic	56 (44)
Ischemic	72 (56)
Stroke hemisphere
Right	75 (59)
Left	48 (37)
Both	5 (4)
Barthel Index (0–100), M (SD)	85.4 ± 17.6

Note. N = 128. IQR = interquartile range.

Internal Consistency

The internal consistency was acceptable with a Cronbach’s α of .80; 95% confidence interval [CI] [0.75, 0.85]. The CITCs had a mean of .44 and ranged between .28 and .55. Table 2 shows the CITCs and Cronbach’s α if an item was deleted.

Table 2.

Corrected Item–Total Correlation and α Value if Item Is Deleted

Item	Corrected Item–Total Correlation	Cronbach’s α if Item Is Deleted
Satisfaction with work	.46	.79
Satisfaction working the past 2 mo	.47	.79
Satisfaction with rehabilitation	.39	.79
Satisfaction with organized hobby	.55	.78
Satisfaction with hobby on independent basis	.39	.80
Satisfaction with cultural activities	.42	.79
Satisfaction with housework	.50	.79
Satisfaction with repair or maintenance jobs	.38	.80
Satisfaction with planning and organizing of the housework	.49	.79
Satisfaction with care of children, parents, or significant others	.28	.80
Satisfaction with daily self-care	.51	.79
Satisfaction with physical exercise	.37	.80
Satisfaction with rest, relaxation, or recharging their batteries	.48	.79

Convergent Validity

Summed scores for participation level and participation satisfaction that were based on the Spanish version of the SDO–OB correlated moderately (ρ = .53, p < .001). Correlations from these two variables to general participation satisfaction were weak (ρ = .33, p < .001) and moderate (ρ = .54, p < .001). There were weak negative correlations with the EQ–5D–5L mobility, self-care, and daily activity components (ρ = −.20 to −0.30, p < .022) and weak positive correlations with the EQ–5D–5L current health status component (ρ = .23 to .37, p < .008). In addition, the summed participation satisfaction scores had a weak negative correlation with the anxiety and depression component (ρ = −0.32, p < .001). All ACS participation areas had a moderate positive correlation with both of the SDO–OB summed scores (ρ = .40–.61, p < .001), except for leisure, which showed a weak positive correlation with both (ρ = .25–.39, p < .006). The correlation coefficients of summed participation level and summed participation satisfaction scores with the variables selected to assess convergent validity are presented in Table 3.

Table 3.

Correlations Between Measures Used to Assess Convergent Validity and SDO–OB Scores

Measure	Correlations for Summed Scores
Measure	SDO–OB Participation Level	SDO–OB Satisfaction With Participation
General participation satisfaction	.33*	.54*
EQ–5D–5L
Mobility	−.20*	−.25*
Self-care	−.26*	−.27*
Daily activities	−.24*	−.30*
Pain	−.06	−.15
Anxiety and depression	−.15	−.32*
Current health status	.23*	.37*
ACS
Instrumental	.61*	.40*
Leisure	.39*	.25*
Social	.45*	.44*
Total	.53*	.41*

Note. Data are expressed in Spearman correlation coefficient. ACS = Activity Card Sort; EQ–5D–5L = five-level version of the EQ–5D; SDO–OB = Satisfaction with Daily Occupations and Occupational Balance.

*p < .05.

Known-Groups Validity

The discriminating ability of the Spanish version of the SDO–OB was evaluated by comparing participants who were stroke survivors with and without a principal caregiver. The group with a principal caregiver showed lower summed scores for participation level (Mann– Whitney U = 5.675, p < .001) and lower summed scores for participation satisfaction (Mann–Whitney U = 3.452, p = .001) than the group without a principal caregiver. Furthermore, the group with a principal caregiver was shown to be underoccupied compared with those without a principal caregiver with regard to home management, χ²(2) = 19.3, p < .001, and general participation balance, χ²(2) = 14.2, p = .001. Descriptive statistics are shown in Table 4.

Table 4.

Scores for Summed Participation Level, Summed Satisfaction With Participation, and Participation Balance Scores for Participants With and Without a Principal Caregiver

Variable	n (%)		p
Variable	Group 1: Participants With Caregiver (n = 68)	Group 2: Participants Without Caregiver (n = 60)	p
Summed participation level score (0–13), Mdn [IQR]	5 [3–7]	8 [6–9]	<.001*
Summed satisfaction with participation score (13–91), Mdn [IQR]	67 [54–74]	74 [67–80]	.001*
Participation balance area
Work
Underoccupied	61 (90)	50 (83)	.493^†
In balance	4 (6)	7 (12)
Overoccupied	3 (4)	3 (5)
Leisure
Underoccupied	20 (29)	17 (28)	.299^†
In balance	30 (43)	19 (32)
Overoccupied	19 (28)	24 (40)
Home management
Underoccupied	54 (79)	25 (42)	<.001^†
In balance	10 (15)	26 (43)
Overoccupied	4 (6)	9 (15)
Self-care
Underoccupied	21 (31)	11 (18)	0.221^†
In balance	32 (47)	36 (60)
Overoccupied	15 (22)	13 (22)
General
Underoccupied	32 (47)	12 (20)	0.001^†
In balance	29 (43)	29 (48)
Overoccupied	7 (10)	19 (32)

Note. IQR = interquartile range.

*p after the Mann–Whitney U test.

†p after the chi-square test.

Intraobserver Reliability

The test–retest reliability was good for summed participation level (ICC = .91; 95% CI [.85, .94]) and summed participation satisfaction (ICC = .86; 95% CI [.78, .92]) scores. The test–retest reliability for the participation balance scores was good for work (agreement: 78%; κ = 0.69) and home management (agreement: 54%; κ = 0.64), moderate for self- management (agreement: 46%; κ = 0.46), and fair for leisure (agreement: 44%; κ = 0.33) and the general item (agreement: 41%; κ = 0.30).

Measurement Error

For the summed participation level scores, SEM and MDC were 0.7 and 1.9 points, respectively. For the summed participation satisfaction scores, the SEM was 4.5 points, and the MDC was 12.4 points.

Floor and Ceiling Effects

The analyses of the distribution of frequencies regarding summed participation level and satisfaction scores showed that 7% of the respondents achieved the lowest or the highest scores, indicating an absence of floor or ceiling effects.

Discussion

In this study, we aimed to evaluate the psychometric properties (internal consistency, convergent validity, known-groups validity, floor and ceiling effects, intraobserver reliability, and measurement error) of the Spanish version of the SDO–OB in people who had experienced a stroke more than 6 mo previously. The analyses of data from a large sample showed acceptable internal consistency. There was a moderate correlation between participation level and participation satisfaction, and both correlated only with those EQ–5D–5L and ACS items that assess the corresponding constructs, indicating acceptable convergent validity. Furthermore, the results showed that the Spanish version of the SDO–OB can discriminate between stroke survivors with a caregiver and those without a caregiver (i.e., known-groups validity). Moreover, the results showed an absence of any floor or ceiling effects, as well as good intraobserver reliability.

Internal Consistency

This study showed that the Spanish version of the SDO–OB has an acceptable internal consistency, which is in line with the Spanish study conducted with people with mental health problems, in which a Cronbach’s α of .75 and a mean CITC of .38 were obtained (Vidaña-Moya et al., 2020). This acceptable internal consistency indicates that the 13 items of the SDO–OB, grouped into four areas (work, leisure, home management, and self-care), homogeneously cover the participation construct and provide comprehensive information. Together with the consistent pattern of correlations with the ASC scores, which reflect participation according to the ICF (American Occupational Therapy Association, 2020; WHO, 2001), these findings suggest that the SDO–OB may provide a broad perspective on participation, compared with most tools used until now (Engel-Yeger et al., 2018; Ezekiel et al., 2019; Magasi & Post, 2010; Prieto-Botella et al., 2022; Tse et al., 2013).

Convergent Validity

Summed scores for participation satisfaction and participation level demonstrated a moderate correlation, which is similar to the findings of the Spanish validation study of the SDO–OB for mental health (ρ = .521; Vidaña-Moya et al., 2020). Accordingly, the higher the level of participation, the higher the satisfaction, and vice versa. Possibly, interventions focused on increasing levels of participation could start an upward spiral that leads to an increase in levels of satisfaction, in turn, promoting continued and increased levels of participation, again leading to increased satisfaction (Dfarhud et al., 2014). Although this is something that needs to be empirically investigated, it has some support in that participation level has been found to be associated with the perception of recovery among stroke survivors (Ezekiel et al., 2019).

To our knowledge, this is the first SDO–OB study to analyze convergent validity using the EQ–5D–5L and the ACS. Weak correlations were found between the EQ–5D–5L and summed level of participation and summed participation satisfaction scores. The correlation was negative for mobility, self-care and daily activities and for anxiety and depression, whereas it was positive for the global level of health to date. The negative correlation between the level of satisfaction and the level of anxiety and depression may be of particular interest, because, according to the WHO in 2030, counteracting anxiety and depression is one of the objectives to be achieved by people who need rehabilitation (Gimigliano & Negrini, 2017), including people who had a stroke (Norrving et al., 2018). These findings confirm our hypothesis that the levels of participation and satisfaction are reflected in the level of self-perceived quality of life, although they also suggest that participation and quality of life are partly separate phenomena.

Furthermore, a positive correlation was found between the level of participation maintained after the stroke measured with the ACS and the summed participation level scores from the SDO–OB. In relation to our hypothesis, the results confirmed that participants who had experienced a lower percentage of change in relation to their prestroke level of participation according to the ACS were those who had higher levels of participation as measured by the SDO–OB. However, a low correlation was found between both summed participation level and summed satisfaction with participation and ACS leisure. This result may be due to the fact that the domain of leisure is only one of several facets in the summed SDO–OB.

According to the prior hypothesis, no relationship was expected between participation maintained measured with ACS and the SDO–OB satisfaction score. However, our findings revealed moderate correlations between the two variables, indicating a potential association between the level of participation and satisfaction with participation. It is important to note that correlation does not imply causality, and further research is needed to understand the nature of this relationship fully. These results suggest that other factors, such as individual lifestyle and health status, may play a role in the interplay between participation maintained and satisfaction with participation (Sarre et al., 2014).

Known-Groups Validity

Although previous studies have demonstrated the ability of the SDO–OB to discriminate between healthy participants and Spanish people with mental health problems (Vidaña-Moya et al., 2020), Arabic stroke survivors (Manee et al., 2015), asylum seekers in Denmark (Eklund & Morville, 2014), and Swedish elderly people inside and outside the health services (Hultqvist et al., 2017), to our knowledge, this is the first study to demonstrate the instrument’s ability to discriminate within a group of Spanish stroke survivors by discerning whether they needed the support of a caregiver. Further studies are needed to understand why participants who had a caregiver had lower levels of participation and satisfaction and an underoccupied situation in relation to participation balance.

Intraobserver Reliability and Measurement Error

Good intraobserver reliability was found, which indicates the stability of the responses to the SDO–OB when the same evaluator collects them. Moreover, future SDO–OB users may benefit from the identified SEM and MDC cutoffs. They would be of great clinical and research relevance for understanding the impact of interventions or other conditioning factors, especially because previous psychometric studies of the SDO–OB did not investigate these properties (Eklund & Morville, 2014; Hultqvist et al., 2017, 2020; Manee et al., 2015; Vidaña-Moya et al., 2020).

Usefulness of the Satisfaction With Daily Occupations and Occupational Balance

On the basis of the present findings, this study proposes the use of the Spanish version of the SDO–OB as a reference tool in the stroke survivor population in both clinical and research settings, because it meets the needs expressed in previous studies (Engel-Yeger et al., 2018; Tse et al., 2013). The Spanish version of the SDO–OB showed psychometric properties that are similar to those of the most widely used tools for the construct of participation. It covers the nine domains listed in the ICF framework and provides, through an interview, information about the level of participation, satisfaction with participation, and participation balance. Although not included in the present study, the SDO–OB can be used to retrieve qualitative information on the basis of the person’s perception of the barriers and facilitators that condition participation (Flokén et al., 2016). Therefore, the widespread use of this tool could help to reduce the heterogeneity among the wide range of tools that measure participation in activities in terms of data provided, forms of administration, and quality of psychometric properties (Eyssen et al., 2011), allowing comparison in clinical and research settings.

Needs for Further Research

Future studies should continue to analyze the properties of this tool, such as interobserver reliability and responsiveness. In addition, upcoming research should focus on a qualitative analysis of the information collected by the Spanish version of the SDO–OB in the stroke survivor population to understand the causes that impede their return to participation and identify factors that may help restore their participation situation, in terms of level, satisfaction with participation, and participation balance.

Including the Spanish version of the SDO–OB in future research with stroke survivors may increase the methodological quality of the tools used and thereby provide relevant information on the impact of interventions or natural development, increasing the scarce consistent evidence to date.

Strengths and Limitations

The methodological design of the study reduced intra- and interobserver biases by having a single-blind evaluator trained in administering the Spanish version of the SDO–OB with no clinical link to the participants. In addition, the study had an extensive sample that included a variety of sociodemographic characteristics, which strengthens both internal and external validity. However, selection criteria excluded those populations to whom it could not be administered because of their clinical situation, such as low cognitive functions and language difficulties affecting expression or comprehension.

Implications for Occupational Therapy Practice and Education

The findings of this study have the following implications for occupational therapy practice and education:

▪ After experiencing a stroke, it is necessary to regain a balanced level of participation in all areas of human occupation.

▪ The SDO–OB is a simple assessment tool to collect relevant information on the participation of stroke survivors and their satisfaction with that situation.

▪ The SDO–OB is able to detect changes in the level of participation and satisfaction of stroke survivors, which is of great importance when occupational therapists evaluate their interventions.

Conclusion

The results of the present study provide support for the use of the Spanish version of the SDO–OB as a reference tool in both clinical and research settings where stroke survivors are the target group to record their participation level, satisfaction with participation, and participation balance.

Footnotes

Acknowledgments

We thank all the Spanish collaborating centers and the collaborating professionals involved for the recruitment of study participants: Asociación de Dano Cerebral da Coruña, Asociación de Enfermos Neurológicos Oscense, Asociación de Daño Cerebral Adquirido de Granada, Asociación de Ictus de Aragón, Asociación de personas con lesión medular y otras discapacidades físicas, Centro de NeuroRehabilitación, Nutrición y Fisioterapia, Centro Integral de Rehabilitación, Grupo 5 Centro Integral de Atención Neurorehabilitadora Navarra, Neurorrehabilitación y Atención al Neurodesarrollo, Centro de Fisioterapia y Neurorrehabilitación, Rehabilitación Neurológica y Desarrollo Infantil, Centre de Rehabilitació Neurològic, and Rehabilitación El Carmen, as well as self‐employed professionals Lezcano Fisioterapia and Juan Luis Abeledo Alcón.

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