Classification of life satisfaction by occupational gaps and its characteristics among older adults with care needs

Abstract

Objective

Occupational therapy aims at enhancing people’s life satisfaction, it is important to focus on the occupational gap between “what they want to do” and “what they actually do.” This study aimed to describe the characteristics of occupational gap of older adults with care needs who are residing at home, and clarify how the occupational gap patterns classify their life satisfaction.

Method

The Occupational Gap Questionnaire was used to assess the occupational gaps of 209 older adults with care needs (80.1 ± 7.5 years old, 42.1% male), and a Classification and Regression Tree analysis was performed.

Results

The most important factor in classifying participants’ life satisfaction was the number of social activities that “they do and want to do,” followed by the number of instrumental activities of daily living (IADLs) that “they do not do but want to do”.

Conclusion

Our results suggest that promoting participation in social activities and IADLs that participants want to do may improve life satisfaction even when care is needed. Our findings indicate that it is important not only to reduce the occupational gap but also to increase the number of meaningful activities they want to do.

Keywords

Occupational gap life satisfaction participation older adults occupational therapy

Introduction

In Japan, the aging population is rapidly growing, and an increasing number of older adults with care needs continue to live in their familiar homes (Ministry of Health, Labour and Welfare, 2019). To promote their health, well-being, and life satisfaction, it is important to provide appropriate support according to individual living situations so that they can indulge in participation despite being in need of care. Participation is defined as involvement in life situations and is considered an important factor that can provide the desired impact on health and well-being (World Health Organization, 2001). Occupational therapists are positioned as rehabilitation professionals who promote health and well-being through people’s participation in activities that are meaningful and valuable to them, that is, occupation (World Federation of Occupational Therapists, 2023). Factors of “participation restrictions” among older adults include illness, frailty, and declining abilities, and it is reported that the frequency of participation decreases with age (Fortuijn et al., 2006). Therefore, older adults with care needs experience challenges with participation.

However, participation can be realized without necessarily improving body functions or body structures (World Health Organization, 2001). Fisher suggests that occupational therapy should focus on improving occupational performance rather than improving underlying impairments (Fisher, 1998). An occupational therapist is a professional who facilitates people’s participation and contributes to the development and enrichment of their lives, regardless of their disability (Law, 2002). The primary goal of occupational therapy is to enable people to participate in everyday life activities, with an emphasis on activities that are meaningful and valuable to them (Fisher, 1998). Therefore, in supporting an individual’s participation in occupational therapy, it is important to focus not only on their ability or performance regarding participation, but also on the “qualitative aspects of participation,” such as how the individual is doing the activities they want to do.

The gap between what the person “actually does” and “wants to do” is called the occupational gap (Eriksson et al., 2006). The Occupational Gaps Questionnaire (OGQ) was developed in Sweden to measure the occupational gap (Eriksson et al., 2006, 2009). The OGQ comprises of 30 activity items in four domains: instrumental activities of daily living (IADL), leisure activities, social activities, and work or work-related activities. The OGQ elucidates two different types of occupational gaps: “activities that they do not do, but want to do” and “activities that they do, but do not want to do.” In addition, the OGQ can assess two different types of “no occupational gap,” such as “activities that they do, and want to do” and “activities that they do not do, and do not want to do.” Each activity item is placed into four types of occupational gap patterns, depending on the responses. The OGQ can be used to identify the number of activities in each occupational gap pattern. Previous studies using the OGQ have found that people five years after stroke onset (Svensson et al., 2019) and people with musculoskeletal pain and stress-related conditions (Eriksson et al., 2012) experience more occupational gaps compared to healthy populations. In addition, associations between occupational gaps and life satisfaction have been reported in people after acquired brain injury (Eriksson et al., 2009) and stroke (Bergström et al., 2017) and in caregivers of stroke patients (Bergström et al., 2015) Previous studies have analyzed by calculating the total number of two types of occupational gaps in the OGQ; however, this has not been validated by examining the characteristics of activity domains and four types of occupational gap patterns in the OGQ. Satisfaction derived from occupational participation is one of the outcomes in occupational therapy (World Federation of Occupational Therapists, 2023), and it is necessary in occupational therapy to understand the characteristics of the individual’s occupational gap and have an analytical perspective on what kind of occupational gap determines their life satisfaction.

The aim of this study was to investigate the characteristics of the occupational gap of older adults with support and care needs at home, and to determine the occupational gap patterns in each activity domain of the OGQ and how they classify their life satisfaction.

Methods

Participants

Participants included individuals aged 65 years old or above, who had resided at home for at least three months from the date of the survey and were certified as requiring support or care under the long-term care insurance system (LTCI) in Japan. The eligibility criteria for the participants were those who received long-term care services and had preserved cognitive functioning to complete a self-rating questionnaire. The occupational therapists and physical therapists selected participants who could communicate without difficulty in daily communication and had sufficient cognitive ability to read, comprehend and answer the questions appropriately. After recruitment, 394 individuals agreed to participate in the survey. With the exception of 185 participants who failed to fill out the necessary questionnaire items, 209 participants were included in the final analysis. The study followed the guidelines of the Declaration of Helsinki and was approved by the institutional ethics committee (IRB: 20-34). All participants provided informed consent.

Instruments

Demographic data

Demographic data included age, gender, and care levels according to the LTCI. The LTCI system is classified into seven levels: Support 1 and 2, which require assistance with activities of daily living, and Care 1 (the least disabling) to Care 5 (the most severe disability), which require ongoing care. The care level is evaluated using a 74-item questionnaire based on activities of daily living (ADL) and a physician’s opinion (Iwagami & Tamiya, 2019; Tsutsui & Muramatsu, 2005).

Assessment of occupational gaps

The Japanese version of the OGQ (OGQ-J) was used to assess the occupational gap, which comprises of 30 items in four domains: IADL (8 items), leisure activities (8 items), social activities (11 items), and work or work-related activities (3 items). The OGQ-J has been psychometrically validated in previous study (Misu et al., 2022). The Rash model was used for psychometric validation of the OGQ-J and internal scale validity. (Misu et al., 2022). Participants were asked two questions: “Do you perform this activity?” and “Do you want to perform this activity?” Answering “Yes” to one question and “No” to the other was determined as an occupational gap. There were two different types of occupational gaps: “activities that they do not do but want to do (Gap 1)” and “activities that they do but do not want to do (Gap 2).” Furthermore, there were two types of no gaps: “activities they do and want to do (No Gap 1)” where the respondent answered “Yes” to both questions, and “activities they do not do and do not want to do (No Gap 2)” where the respondent answered “No” to both questions (Table 1).

Table 1.

Occupational gap patterns based on answers to OGQ-J questions.

OGQ-J question	No gap		Gap
OGQ-J question	No gap 1	No gap 2	Gap 1	Gap 2
Do you perform this activity?	Yes	No	No	Yes
Do you want to perform this activity?	Yes	No	Yes	No

OGQ-J; Japanese version of Occupational Gaps Questionnaire.

No gap 1; Activity that they do and want to do.

No gap 2; Activity that they do not do and do not want to do.

Gap 1; Activity that they do not do but want to do.

Gap 2; Activity that they do but do not want to do.

Assessment of life satisfaction

The Japanese version of the life Satisfaction Checklist (LiSat-11) (Kajiwara et al., 2015) was used to assess life satisfaction. The LiSat-11 contains 11 items: 1 global satisfaction and 10 domain-specific satisfaction questions. The first question of the LiSat-11, “Life as a whole is …?” is used to comprehensively assess life satisfaction, and is rated on a 6-point self-rating scale, ranging from 1 “very dissatisfying” to 6 “very satisfying.” In this study, the global satisfaction question was used in accordance with previous studies (Bergström et al., 2012, 2015). The first question in LiSat-11 - the global satisfaction question - has been used in previous studies as a comprehensive assessment of life satisfaction (Bergström et al., 2012, 2015; Viitanen et al., 1988). LiSat-11 scores are often dichotomized into “dissatisfied” and “satisfied.” The answer “rather satisfied” has two patterns: one is classified as “satisfied” (Hartman-Maeir et al., 2007; Wenneberg et al., 2022) and the other is classified as “dissatisfied” (Bergström et al., 2015; Eriksson et al., 2009) which differs from the previous studies. Since the level of life satisfaction among the Japanese is lower than that of other countries (Park et al., 2019), this study included “rather satisfied” in the “satisfied” category, and classified a score of 1–3 as “dissatisfied” and a score of 4–6 as “satisfied.”

Data collection

Participants were older adults who are residing at home and using either community or home-based rehabilitation services. Participants were informed about the study by their occupational or physical therapists when they received rehabilitation services. Participants who agreed to participate in the study were provided a questionnaire and a return envelope, and answered the questionnaire anonymously without the support of others. The questionnaire included demographic data, LiSat-11, and OGQ-J. Participants were asked to answer the questionnaire and post it in a self-addressed envelope to the researcher. For cases where participants had difficulties getting to the mailbox on their own, their therapists mailed the questionnaires back to the researcher on their behalf.

Statistical analysis

Describing the characteristics of the occupational gaps

From the OGQ-J responses, each of the 30 activities was categorized into four occupational gap patterns. Thereafter, activities that were selected for each occupational gap pattern were tabulated to understand the characteristics of the occupational gap.

Classification of life satisfaction by occupational gaps

The Classification and Regression Tree (CART) analysis was performed to identify the occupational gap that determined life satisfaction. The CART analysis is a statistical method that optimally divides the parent node into two child nodes by a division criterion called the Gini impurity function, when the dependent variable is a categorical variable (Garzotto et al., 2005; Lemon et al., 2003). Furthermore, it has a feature of representing the classification in a tree diagram, which visually and intuitively facilitates the understanding of statistical results. The beginning of the node containing the entire sample is called the parent node and the node branching into two nodes is called the child node. In CART analysis, the maximum number of levels to which a tree can grow (tree depth) and the minimum number of individuals in the child or terminal node are defined to control the size of the tree (Lemon et al., 2003).

In this study, 30 activity items from participants’ responses were tabulated for each of the four OGQ-J domains (IADL, leisure activities, social activities, and work or work-related activities) and four occupational gap patterns (Gap 1, Gap 2, No Gap 1, and No Gap 2). The CART analysis was performed using the state of life satisfaction (“dissatisfied” or “satisfied”) as the objective variable and demographic data (age, gender, and care level) and four occupational gap patterns for each activity domain (a total of 19 variables) as explanatory variables. In the CART analysis, the decision tree was constructed using the Gini impurity function with a maximum tree depth of 5 and a minimum number of cases for the terminal node was set to 20. The classified decision trees were visualized and their accuracy was evaluated using a confusion matrix. Statistical analysis was conducted using R (version 4.2.1, R Foundation for Statistical Computing, Vienna, Austria).

Results

Participants’ characteristics

Table 2 shows the demographic data and results of the OGQ-J and LiSat-11. The mean age of the participants was 80.10 ± 7.51 years. There were 121 (57.9%) females and 88 (42.1%) males. The care levels were as follows: 78 (37.3%) were support level 2; 40 (19.1%) were care level 1; 37 (17.7%) were support level 1; 27 (12.9%) were care level 2; 17 (8.1%) were care level 3; 7 (3.3%) were care level 4; and 3 (1.4%) were care level 5. Regarding life satisfaction, 86 (41.1%) reported rather satisfied; 58 (27.8%) reported satisfied; 38 (18.2%) reported rather dissatisfied; 14 (6.7%) reported dissatisfied; 9 (4.3%) reported very satisfied; and 4 (1.9%) reported very dissatisfied. The median (range) of the occupational gap, “No Gap 2” was 13 (0–28), “No Gap 1” was 11 (0–30), “Gap 1” was 3.5 (0–22), and “Gap 2” was 0 (0–17).

Table 2.

Characteristics of the Study Participants (n = 209).

Variables	n, mean, median	%, SD, range
Age, mean (SD), years	80.10	7.51
Sex, n (%)
Male	88	42.1
Female	121	57.9
Care level, n (%)
Support level 1	37	17.7
Support level 2	78	37.3
Care level 1	40	19.1
Care level 2	27	12.9
Care level 3	17	8.1
Care level 4	7	3.3
Care level 5	3	1.4
LiSat-11, n (%)
Dissatisfied	56	26.8
Very dissatisfying	4	1.9
Dissatisfying	14	6.7
Rather dissatisfying	38	18.2
Satisfied	153	73.2
Rather satisfying	86	41.1
Satisfying	58	27.8
Very satisfying	9	4.3
OGQ-J, median (range)
No gap 1	11	0–30
No gap 2	13	0–28
Gap 1	3.5	0–22
Gap 2	0	0–17

LiSat-11; Life Satisfaction Checklist.

OGQ-J; Japanese version of Occupational Gaps Questionnaire.

No gap 1; Activity that they do and want to do.

No gap 2; Activity that they do not do and do not want to do.

Gap 1; Activity that they do not do but want to do.

Gap 2; Activity that they do but do not want to do.

Characteristics of occupational gaps

Table 3 shows the tabulated results of the activities in each occupational gap pattern. The activities selected by approximately 90% of the participants as “No Gap 1” were “watching TV/video/listening to music, or the radio” (90.0%) and “getting information” (86.6 %). On the contrary, activities that were selected by fewer than 10% of the participants were “performing heavy maintenance of your home, garden, car” (6.7%), “working for payment” (7.7%), “studying” (8.1%), and “voluntary efforts” (8.6%). The following four activities were selected by approximately 80% of the participants as “No Gap 2:” “working for payment” (84.2%), “performing heavy maintenance of your home, garden, car” (81.8%), “studying” (79.9%), and “voluntary efforts” (78.9%). The activities selected as “Gap 1” were “travelling” (38.8%), “participating in cultural activities” (28.7%), and “participating in outdoor activities” (28.2%). The activities selected by approximately 10% of the participants as “Gap 2” were “doing laundry” (11.0%) and “cleaning” (10.0%).

Table 3.

Distribution of Four Difference Types of Perceived Occupational Gaps (n = 209).

Activities	No gap 1	No gap 2	Gap 1	Gap 2
IADL
Grocery shopping	43.5	30.1	23.0	3.3
Preparing for meals	47.4	35.9	10.0	6.7
Doing laundry	50.7	31.6	6.7	11.0
Cleaning	37.3	34.4	18.2	10.0
Performing a light maintenance of your home, garden, car	36.4	37.3	19.1	7.2
Performing heavy maintenance of your home, garden, car	6.7	81.8	9.1	2.4
Managing personal finances	57.4	30.6	8.1	3.8
Transporting oneself using a vehicle	44.5	29.2	19.6	6.7
Leisure activities
Shopping	41.6	30.6	23.0	4.8
Participating/taking an interest in sports	18.7	53.1	26.3	1.9
Participating in outdoor activities	29.7	39.7	28.2	2.4
Having a hobby	37.3	39.2	21.5	1.9
Participating in cultural activities	15.3	55.0	28.7	1.0
Watching TV/videos/listening to music, or the radio	90.0	2.9	3.3	3.8
Getting information	86.6	5.7	3.8	3.8
Reading	42.1	40.7	14.8	2.4
Writing	46.4	38.8	12.0	2.9
Playing games	15.3	76.6	7.2	1.0
Using digital devices	51.2	35.4	8.6	4.8
Social activities
Visiting/socializing/having contact with family or relatives	58.4	19.6	20.1	1.9
Visiting/socializing/having contact with boy- or girlfriends, friends, or neighbors	53.1	26.8	18.7	1.4
Helping and supporting others	21.1	52.2	25.4	1.4
Participating in regional/group activities	21.5	59.8	15.3	3.3
Religious activities, worship	55.0	24.9	16.7	3.3
Eating out	41.1	34.0	23.9	1.0
Travelling	13.9	46.9	38.8	0.5
Dressing up	38.8	45.9	12.4	2.9
Work or work-related activities
Working for payment	7.7	84.2	7.7	0.5
Studying	8.1	79.9	11.0	1.0
Voluntary efforts	8.6	78.9	12.0	0.5

IADL; instrumental activities of daily living.

OGQ-J; Japanese version of Occupational Gaps Questionnaire.

No gap 1; Activity that they do and want to do.

No gap 2; Activity that they do not do and do not want to do.

Gap 1; Activity that they do not do but want to do.

Gap 2; Activity that they do but do not want to do.

The numbers in the table indicate percentages. Activities selected by more than 30% of the respondents are shown in bold.

Occupational gap by domain of life satisfaction classification

The results of the LiSat-11 questionnaire classified 56 (26.8%) and 153 (73.2%) participants in the dissatisfied and satisfied groups respectively. Figure 1 shows the decision tree generated by the CART analysis. The number of “No Gap 1” in social activities, and the number of “Gap 1” in IADL, age, and care level were selected as nodes to classify life satisfaction.

Figure 1.

The decision tree generated by the CART analysis. Social_No Gap 1; Social activity that they do and want to do. IADL_Gap 1; IADL that they do not do but want to do. Top number: 1 indicates a high percentage of satisfied participants; 0 indicates a high percentage of dissatisfied participants. Middle number: percentage of dissatisfied (left) and satisfied (right) participants. Bottom number: of the total number of participants, percentage of participants included in that node. Node branching: left indicates “Yes,” and right indicates “No.” The CART analysis was performed using the state of life satisfaction (“dissatisfied” or “satisfied”) as the objective variable and demographic data (age, gender, and care level) and four occupational gap patterns for each activity domain (a total of 19 variables) as explanatory variables. In the CART analysis, the decision tree was constructed using the Gini impurity function with a maximum tree depth of 5 and a minimum number of cases for the terminal node was set to 20.

The root node for classifying life satisfaction was selected as “No Gap 1” in social activities. Eighty-three percent of the participants with three or more “No Gap 1” in social activities were classified as satisfied. Among participants with less than three “No Gap 1” in social activities, the next most important prediction factor was the number of “Gap 1” in IADL. Seventy-two percent of the participants with more than three “Gap 1” in IADL were classified as dissatisfied. The next factor in classifying participants with less than two “Gap 1” in IADL was age. If age was older than 89, ninety percent of the participants were classified as satisfied. Participants under 89 years were classified by the number of “No Gap 1” in social activities. At the parent node of the leaf node, the care level was selected. Seventy-five percent of the participants were classified as dissatisfied if their care level was 4 or higher.

In the classification model presented in the CART analysis, the number of cases that were correctly classified as life satisfaction from the confusion matrix was 146 and 19 for satisfied and dissatisfied, respectively, with a classification accuracy of 78.9%.

Discussion

Characteristics of the occupational gaps

The OGQ-J was used to tabulate occupational gaps among older adults with care needs. Activities selected by around 90% of the participants as “No Gap 1” were “watching TV/video/listening to music or radio” (n = 189, 90.4%) and “getting information” (n = 182, 87.1%). “Getting information” included “reading the newspaper” and “using the internet,” which were less physically burdensome activities. On the contrary, only 14 (6.7%) respondents selected “performing heavy maintenance of your home, garden, car,” 16 (7.7%) respondents selected “working for payment,” 17 (8.1%) participants selected “studying,” and 18 (8.6%) respondents selected “voluntary efforts.” A large number of participants selected these activities as “No Gap 2.” Moreover, a large number of participants selected the three “work or work-related activities” from the OGQ domains as “No Gap 2.” “Performing heavy maintenance of your home, garden, car” was the most physically burdensome activity in the IADL. The results suggest that physical burden, social role, and responsibility in the activity may influence older adults’ need for participation in the activity.

Although the number of respondents with perceived occupational gaps was low in general, “Gap 1” was observed in social and leisure activities, with 81 (38.8%) respondents in “travelling,” 60 (28.7%) in “participating in cultural activities,” and 59 (28.2%) in “participating in outdoor activities.” The activities selected as “Gap 2” included IADL, with 23 (11.0%) and 21 (10.0%) respondents selecting “doing laundry” and “cleaning,” respectively. Likewise, previous studies with older adults undergoing rehabilitation reported that more participants perceived “Gap 1” in leisure and social activities than in IADL (Bergström et al., 2012). The present results indicated that older adults with care needs faced challenges in participating in leisure and social activities.

Although previous studies have reported on the occupational gap among stroke survivors (Bergström et al., 2017; Eriksson et al., 2006; Fallahpour et al., 2011a), to the best of our knowledge, this is the first study to report on the occupational gap among community-dwelling older adults with care needs. Owing to the lack of information on the medical history of the participants in this study, it is not possible to mention the percentage of those experiencing occupational gaps compared with previous studies. However, considering previous studies (Fallahpour et al., 2011b), the proportion of those who experienced an occupational gap was lower than expected. A study on healthy participants reported a decrease in the number of occupational gaps with age (Eriksson, 2020). This suggests that the number of activities one wants to perform decreases with age. In previous studies, the total number of “Gap 1” and “Gap 2” was often analyzed as the number of occupational gaps. However, in the present study, the responses obtained were tabulated by the gap patterns, and the characteristics of occupational gaps of older adults with care needs were identified in further detail. Occupational gaps in what they “do not do” but “want to do” occur only if the person wants to perform an activity. In other words, the fewer activities they want to perform, the smaller this type of occupational gap will be. Therefore, it is possible to provide appropriate occupational therapy that considers the occupational gap patterns by focusing not only on the occupational gap, but also on activities without an occupational gap that “they do not do, and do not want to do.”

Decision tree analysis by CART

The results of the CART analysis showed that the number of “No Gap 1” in social activities and the number of “Gap 1” in IADL were important factors in classifying life satisfaction. The status of “participation” came out to be a more important factor in classifying participants’ life satisfaction than their care level or age. The number of “No Gap 1” in social activities was the most important factor in classifying life satisfaction among the four occupational gap patterns in each domain of the OGQ-J. It was suggested that increasing the number of social activities that “they do and want to do” is the key to improving life satisfaction among older adults with care needs. Previous studies have reported that satisfaction with participation in social activities is a more important predicting factor for the quality of life of community-dwelling older adults with disabilities than the amount of participation (Levasseur et al., 2008). The findings of the present study support previous research suggesting that participation as “they want to perform” in social activities is important for life satisfaction. However, it has been reported that aging and declining physical functions are associated with constrained life spaces (Dunlap et al., 2022), which may reduce opportunities for participation in social activities for older adults. It is also reported that older adults with disabilities who use home care services have unmet needs for social activities rather than daily activities (Turcotte et al., 2015); thus, participation in social activities for older adults with declining physical function is a challenge. Older adults with care needs may be reluctant to participate in social activities because they require personal assistance and many environmental adaptations for participation. If the occupational therapist suggests strategies to remove personal and environmental barriers that restrict participation, the participants may show an interest in participation in social activities.

When the number of “No Gap 1” in social activities was less than two, then the next most important factor determining life satisfaction was the number of “Gap 1” in IADL. Three or more gaps of this type in IADL indicated that participants were more likely to be dissatisfied with their life. In a previous study comparing the characteristics of the occupational gap between Swedish people who were recruited from the general population and undergoing rehabilitation owing to stress-related illness or musculoskeletal pain, the proportions of the two types of occupational gaps showed similar distribution trends in the two groups. However, the two types of occupational gaps in IADL showed different distributions. The group undergoing rehabilitation was reported to have a higher percentage of activities they do not do but want to do than the control group, whereas the control group had more activities they do but do not want to do than the rehabilitation group (Eriksson et al., 2012). IADL are activities closely related to daily life among the four domains of the OGQ, and have the characteristic that people “do not want to do” when they are able to do the activity, but begin to “want to do” when they have reduced their daily functioning and are unable to do the IADL that they used to commonly do. In an 8-year longitudinal study of Japanese older adults, social role functions were reported to be the first to be lost with aging, followed by intellectual activities and IADL (Fujiwara et al., 2003). Participation in IADL is an activity that becomes a goal until the end of life for older adults with decreased social activity, and thus, this may have a high level of importance and priority for participation. Therefore, in the decision tree analysis in this study, the high number of IADL that “they do not do but want to do” is considered to have increased the possibility of classifying the participants’ life satisfaction as unsatisfactory.

Previous studies have reported that the fewer the number of occupational gaps, the higher the level of life satisfaction (Bergström et al., 2017; Eriksson et al., 2009). However, it is important not only to reduce the number of occupational gaps, but also to increase the number of activities “they want to do” and support them to perform those in occupational therapy, which can help improve the life satisfaction of older adults with support and care needs.

Limitations of the study

This study included older adults who were evaluated as needing support and care under the long-term care insurance system in Japan and those who used home care services. However, the study used a self-rating questionnaire, and the participants’ care level was relatively mild. Therefore, the results of this study could not be generalized to people with intensive care needs. Further study should include people with intensive care levels to examine their occupational gap and life satisfaction in further detail.

Conclusions

In summary, the number of social activities that “they do and want to do” and the number of IADL that “they do not do but want to do” were found to be important factors in classifying the life satisfaction of older adults with care needs. The results suggest that participation in social activities and IADL may promote life satisfaction among older adults with care needs.

In occupational therapy, it is important to reduce the number of occupational gaps, and increase the number of meaningful activities that the person wants to perform and help them participate in those activities.

Footnotes

Acknowledgements

All authors would like to thank all facilities and participants for their cooperation in this study.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Yuka Misu

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