Abstract
Background
Community occupational therapy forms a critical primary health service in supporting the development of young children. This study aims to explore characteristics of service provision, parent rated outcomes and the relationship between dosing and service outcomes.
Methods
A retrospective file review was completed to examine the services received by 60 children, aged 0–6 (mean age 3.8 years). Characteristics of service provision were described. Parent-reported performance and satisfaction scores of the Canadian Occupational Performance Measure (COPM) before and after the intervention were compared. Spearman rank order correlation was used to explore the relationship between intervention “dose” and therapy outcomes.
Results
Most children (n = 51; 85%) received individual therapy for handwriting and motor skills. The average wait time was 26.4 weeks (SD = 19.0). Results of COPM showed improvements in both performance and satisfaction scores (ps < 0.001). Spearman rank order correlation showed no relationship between dosing and outcomes. This study has reported the predominant service provision around handwriting and motor skills with a long wait time.
Conclusion
Findings may assist in future service development, including the service to be provided, considering wait times and equity considerations. Further work is needed to explore what dosage yields the best outcomes.
Introduction
Occupational therapists use a variety of approaches to promote young children’s participation in meaningful activities of everyday life (Clark & Kingsley, 2020), considering the complex interplay between the child, family and environment (Chapparo et al., 2017). However, not all services are equally accessible. For children with additional vulnerabilities or who are considered high risk, access to primary health services in early childhood may be critical in supporting development of children before they start school (Bull et al., 2022), particularly because developmentally vulnerable children are more likely to miss out on health care (Woolfenden et al., 2020).
Currently, there are a range of approaches which may have moderate to good evidence when supporting children’s occupations across a range of target areas such as motor skills, cognition, behaviour and self-care (Clark & Kingsley, 2020). Occupational therapy interventions targeting motor skills for young children are prevalent in literature, but there was little clear guidance on the most suitable intervention intensity, duration, or frequency (Clark & Kingsley, 2020; Novak & Honan, 2019). Motor skills groups have been found to be effective for young children, however, intervention type, duration and frequency differed for each study. For example, a Chilean study reported positive outcomes from a motor skills group for three-year-old children following 6 months of intervention, three times per week (Monsalves-Alvarez et al., 2015). While these positive findings are promising, many services are not able to match this duration and frequency and other scholars have reported positive outcomes in less time. Older work by Ohl et al. (2013) in the USA demonstrated effectiveness of a 10-week (weekly) school-based intervention for motor skills for children aged five, with a combination of classroom-based activities and teacher consultation with children with no particular disabilities. While findings were positive, effect sizes were small and authors concluded that a longer intervention timeframe may have strengthened the positive results. Positive outcomes for motor skills have been reported for shorter intervention timeframes, with Henderson et al. (2022) demonstrating positive outcomes in a 6 week × 90-minute school starters occupational therapy group. Henderson et al. (2022) concluded that brief group interventions could be effective in meeting desired outcomes. Frequency, duration and type of intervention activities varied across these studies, and there were no clear links established between the positive outcomes observed and intervention duration and frequency. Conversely, a US based study by McManus reported that increased frequency and duration of early allied health intervention was associated with improved social and cognitive outcomes as rated by the Child Outcomes Survey for 24-month-old children (McManus et al., 2019). However, more research is needed to gain a clear indication of the specific elements which yield more favourable outcomes in occupational therapy interventions for children (Kingsley & Mailloux, 2013).
In addition to intervention frequency and duration, there are a range of considerations which could influence outcomes in occupational therapy interventions for children. Intervention format, which often comprises individual therapy (Ashburner et al., 2014) or group therapy (Henderson et al., 2022) could have an impact on therapy outcomes. However, studies have shown positive outcomes for using both group and individual therapy formats (Clark & Kingsley, 2020; de Hóra et al., 2019), leaving a lack of clarity about the best approach to take. Other service characteristics may influence outcomes including service setting (home, school or clinic) and the use of evidence based interventions within sessions (Kingsley & Mailloux, 2013), the therapist’s own clinical experience and professional reasoning (Gee et al., 2017), parental engagement (D'Arrigo et al., 2020), parental capacity (Smith & Gallego, 2021) and the suitability of outcome measures (Verkerk et al., 2021). The client centred nature of occupational therapy practice necessitates the use of outcome measures which reflect an individual client’s occupational goals (Pollock et al., 2014), including what is meaningful for children and families (Mathews et al., 2020), such as the Canadian Occupational Performance Measure (COPM) (Law et al., 1990).
Resource constraints in occupational therapy service delivery have been known to influence various service characteristics and how services are delivered. Within community based public health services, a well noted constraint is long wait times for therapy services (Camden et al., 2013). Equity considerations in health service planning may mitigate the impact of delayed service delivery for vulnerable children (Bull et al., 2022). These include careful consideration of intervention “dosing” (duration and frequency) or prioritising vulnerable or “at risk” children to receive a service before others, for example children from culturally and linguistically diverse backgrounds as highlighted in an Australian study by Smith and Gallego (2021). Another Australian study reported that young children from lower socioeconomic backgrounds were also reported as less likely to access health services, even though they may have had greater need (Woolfenden et al., 2020). Both studies identified family health literacy and cultural suitability of health services as particular considerations that can impact health service access and service delivery. However, neither study explored access to occupational therapy services particularly, discussing health services more broadly. Timely and effective access to health services in early childhood is critical for vulnerable children and families and public health services have an important role to play in supporting these children and families (Oral et al., 2016). Offering health services to more vulnerable children sooner may decrease the likelihood of adverse childhood experiences which can negatively impact adult outcomes (Oral et al., 2016). To date, limited studies have explored broad service characteristics, service outcomes and the relationship between intervention “dosing” and therapy outcomes in children’s occupational therapy, leaving a gap in the literature.
The present study took place in Australia where universal fee-free public health services are available including inpatient, outpatient and community services. This study focuses on one community children’s occupational therapy service in an outer metropolitan region. There is a critical need to explore this kind of service provision to inform decisions about effectiveness of a service, prioritisation, intervention format, dosing and improvements required (Moule et al., 2017). Previous Australian studies of health service usage in similar health contexts have not explored occupational therapy service provision specifically (Smith & Gallego, 2021; Woolfenden et al., 2020).
This study had three aims. First, to review and describe the characteristics of occupational therapy services for children and families. The second aim was to evaluate service provision in relation to parent-rated performance and satisfaction as measured by the COPM. Third, to explore the relationship between intervention dosing and type of occupational therapy session offered and service outcomes.
Methods
This study employed a retrospective file review using clinical data collected during routine service provision. Clinical records were retrieved and reviewed in accordance with methods described by Sarkar and Seshadri (2014). Ethical approval was obtained from both South Western Sydney Local Health District Human Research Ethics Committee (SWSLHD HREC) (2019/ETH09787, March 2019) and Western Sydney University Human Research Ethics Committee (WSU HREC) (approval number: H13451, August 2019), which included approval to analyse secondary retrospective data collected during routine service provision with a waiver of consent.
Description of community health service
The health service under investigation offers fee-free occupational therapy assessment and intervention services to local children across six community health centres. These comprise group and individual sessions at one of the centres as well as consultation services to local schools and pre-schools. Children from birth to 12 years are eligible to receive services if they live or attend school in the targeted local government areas. The region targeted in this study was a large outer metropolitan area of a large city covering both urban and rural locations. This region has a higher level of socioeconomic disadvantage and a higher proportion of cultural diversity (South Western Sydney Local Health District, 2019). Children can be referred to the occupational therapy service through their parent or carer, health professional or community service provider. The service is not targeted towards any specific disability or condition, but rather, children can be referred if any mild developmental concerns may exist.
Following referral to the service, children undergo priority screening to determine when they will be seen by an occupational therapist. Priorities are determined based on risk factors associated with adverse childhood experiences (Oral et al., 2016). Children aged under 12 months and families classified as ‘high risk’ (Priority 1A) are considered vulnerable due to medical or social complexities (e.g., diagnosed or suspected physical, medical or developmental disabilities, out of home care or abuse or neglect history, refugee status or Aboriginal or Torres Strait Islander children). Children without these vulnerabilities were given a lower priority rating. Children aged 1–2 years 11 months were Priority 1B, and children aged 3 years–6 years 6 months respectively (approximately the beginning of formal schooling) were Priority 1C. The COPM was completed routinely by the treating therapist in consultation with the child’s parent/caregiver before and after intervention.
Participants
Data were collected retrospectively from clinical files. Data was included for participants who attended the community occupational therapy service during one calendar year (January to December), and were designated as “Priority One” (high risk- 1A, 1B and 1C) to receive a service. Children in the highest priority category were chosen as timely occupational therapy service provision is a particular priority for vulnerable children and those who have not yet started school, and timely service provision may positively impact children’s outcomes (Woolfenden et al., 2020).
A sample size calculation was conducted using G* Power software for two-tailed dependent samples testing (such as Wilcoxon signed ranks test) with an alpha level of 0.05, to minimise Type I error and power of 0.9 to minimise the Type II error and enhance the effect size (Serdar et al., 2021). A minimum sample of 44 participants was required to ensure the study was adequately powered with a moderate effect size (0.5) (Faul et al., 2009). Sample size determination was made considering the balance of data available from the health service, the resource constraints within the research team and the number of observations required to answer the research question (Lakens, 2022).
Measures
Data collection tool
The data collection tool to answer the research aims was collaboratively designed by authors (CM, SR, AZ & KH). Information retrieved included the child’s age, family demographics, timing of their referral, wait time for the service, open text description of occupational therapy goal areas, types and mode of intervention received (e.g. single vs. multidisciplinary or group vs. individual), duration of intervention, number of sessions each child received, and COPM scores before and after the intervention and details of the closure of the service. Wait times were computed by calculating the time between initial referral date to the child’s first face-to-face appointment with a therapist at the centre. Duration of service was calculated by measuring the time in weeks from first assessment until discharge from the service. A random subset of the data collected was checked for accuracy by the second author.
Canadian Occupational Performance Measure (COPM)
The COPM (COPM, 2022; Law et al., 1990) is a commonly used tool in occupational therapy practice which allows the identification and measurement of target areas of importance for the person or their young child. The COPM is rated on a 1-10 scale based on two key elements: the person’s perception of how well they perform in a particular target area and how satisfied they are with that performance. Following occupational therapy intervention, COPM can be used again to measure the person’s perception of change (COPM, 2022). For the present study, COPM was used as the outcome measure to capture the change in parent-rated performance and satisfaction before and after the intervention to address the second research aim. The COPM has good reliability and validity and is commonly used in occupational therapy practice (COPM, 2022). Since the mean age of children included in this study was 3.8 years, with all children being under the age of seven, COPM rating was completed by parents during a semi-structured interview (Pollock et al., 2014) where parents identified target intervention areas and rated their performance and satisfaction on a 1–10 scale. Therapists used a visual scale with numbers (0–10) or smile faces (without numbers) at times to facilitate parent understanding as per COPM cross cultural administration guidelines (COPM, 2022). The measure was completed before intervention activities commenced and again after intervention activities were completed and was administered by registered Occupational Therapists as part of routine service provision.
Procedure
Following ethical approval, data were retrieved through a retrospective file review by three occupational therapy students trained as research assistants and data collection was overseen throughout the process by researchers (CM, KL, JS and KH). Research assistants collected data from either electronic or paper files. Data from each child was entered verbatim from the medical file into the data collection tool using a participant identifier code to ensure the child and family’s confidentiality (See Supplemental File 1). Each file extraction was carefully checked by SR. From the 60 files that were retrieved and used for this study, there was no missing data. Additionally, 10% of the files had their data extraction checked by KH and JS and no errors were identified. Research assistants checked in with lead researchers on a weekly basis throughout data collection and any concerns or discrepancies with files were addressed to ensure consistency in the process.
Data analysis
Qualitative data analysis
Qualitative descriptive content analysis was performed on the open text describing the target intervention areas (Renz et al., 2018). Intervention areas were grouped into eight categories according to occupations and performance skills as outlined in the Occupational Therapy Domain and Process, fourth edition (OTDP-4) (Boop et al., 2020).
An experienced qualitative researcher (CM), who was independent of the therapy service, completed the analysis. First, the text was read several times, the types of intervention were grouped according to the predetermined categories (Renz et al., 2018) and counted the number of occurrences. Completed content analysis was then provided to the project team for checking.
Quantitative data analysis
Information from the data collection tool was entered into the Statistical Program for Social Sciences computerised program (SPSS, Version 28) for analysis. Descriptive statistics were reported to summarise the characteristics of children, families and service provision to address the first aim.
When analysing the difference in COPM before and after the service, non-parametric statistical analysis was used due to the ordinal nature of the data. A Wilcoxon-signed ranks test was used to report on the differences before and after the intervention for performance and satisfaction scores on the COPM (Pallant, 2020) to answer the second research aim. Effect size correlation coefficients (r) were calculated to describe the magnitude of statistical differences identified. This was achieved by dividing the z statistic by the square root of the total number of observations as described by Pallant (2020). Effects sizes are characterised as small (r = 0.1), medium (r = 0.3) and large (r = 0.5) (Pallant, 2020).
Spearman’s rank order correlation (r ) was conducted to determine the relationship between the amount of sessions (measured as amount of individual occupational therapy sessions, amount of group sessions involving an occupational therapist and the total number of sessions overall) and the results of the COPM (performance and satisfaction) for each of the 60 children. Spearman’s rank order correlation (non-parametric) was chosen as the data analysed were not normally distributed and cannot be assumed to be linear (Gravetter & Wallnau, 2013). Analysis with Spearman’s rank order correlation yields a score between 0 and 1, with results closer to +1 or −1 indicating a stronger positive or negative relationship respectively (Lawson et al., 2019).
Results
Descriptive characteristics of children and service provision
Demographics of Children, Families and Service Provision.
KEY: M = mean, SD = standard deviation, N = number, % = percentage of group/sub-group total.
The most common therapy session format was direct individual occupational therapy sessions with a mean number of 4.7 individual sessions per child (Table 1). Three quarters of the children received single discipline sessions by an occupational therapist, which was more than multidisciplinary sessions conducted in collaboration with speech pathology or physical therapy. Home sessions and school/preschool visits were a lot less frequent. Of note is that 30 out of 60 children received more than one session type, for example, they may have attended individual sessions and group therapy sessions. Overall, children received an average of 7.1 therapy sessions as part of the service.
Wait times for service provision varied depending on children’s priority sub-category (Table 1). Overall average wait times were 26.4 weeks, with children in the Priority 1B group having a long wait time of 47.6 weeks. Children designated as ‘high risk’ (Priority 1A) waited the least amount of time of 6.4 weeks. Children spent just over a year in the service on average.
Children were most commonly discharged from the service when their therapy goals were achieved or their therapist determined that they were ‘within normal limits’ for their age.
Descriptive content analysis of target areas for occupational therapy intervention
Overview of reported target areas for occupational therapy according to occupations and performance skills from children’s files.
KEY: COPM = Canadian Occupational Performance Measure, AOTA = American Occupational Therapy Association, n = number of children with file observations.
Parent-rated outcomes using COPM
Results of Wilcoxon signed ranks test for Canadian Occupational Performance Measure (COPM) analysis.
Note. N = Total number of participants; M = Mean; SD = Standard deviation; SoR = Sum of Ranks.
Relationship between occupational therapy intervention type and “dosing” and outcomes
Results of Spearman’s rank order correlation (n = 60).
Key: OT = occupational therapy/therapist, COPM = Canadian Occupational Performance Measure, r = Spearman’s rank order correlation coefficient, p = alpha value.
Discussion
The study explored community occupational therapy service provision, describing service characteristics and the children and families who received the service. Results showed that children mostly attended individual occupational therapy sessions addressing handwriting and motor skills and that children who were designated as “high risk” (Priority One) waited less time to receive a service than others. There was also a significant improvement observed in parent-rated COPM scores for both performance and satisfaction following occupational therapy intervention. However, there was no significant relationship observed between the amount of occupational therapy sessions received and COPM scores.
This study found that most children who attended the service received individual occupational therapy sessions. This observation is consistent with literature that indicates individual therapy sessions are more frequently adopted than group sessions when delivering occupational therapy services to children. A preference for individual occupational therapy sessions over group sessions has been reported in a qualitative study of South African autistic children aged 2–12 years (Moosa et al., 2023), however, therapists reported that costs and staffing made individual service delivery challenging. Conversely, a systematic review by de Hóra et al. (2019) reported that group-based interventions were implemented as often as individual interventions for children (aged 0–18) with developmental coordination disorder. Both these studies adopted different methodologies which may have explained the different findings, however, neither study was able to make a determination about whether individual or group-based interventions were more effective in achieving outcomes. The provision of individual intervention sessions may afford therapists the option for individualising therapy services to child and family needs which may improve therapy outcomes overall (LaForme Fiss, 2012). However, the provision of group-based interventions may afford greater efficiency in service provision, allowing more children to receive a service at the same time, reducing wait times, while still achieving positive outcomes (Camden et al., 2013; Henderson et al., 2022).
Handwriting and motor skills were the most commonly observed target intervention areas in the present study. Motor skills including handwriting are important for occupational performance, in particular, motor skills that fit successfully with the requirements of various tasks (Chapparo et al., 2017). This finding is in line with previous studies which report that handwriting and motor skills interventions are commonly utilised in children’s occupational therapy addressing various motor-based difficulties, such as developmental coordination disorder (Camden et al., 2012), to prepare pre-school children for school (Henderson et al., 2022) and to support children with school and literacy participation (Grajo et al., 2020).
Another important finding was that there were significant improvements in parent rated COPM scores for performance and satisfaction after community occupational therapy intervention with a large effect. This finding may serve as a preliminary indication of effectiveness of occupational therapy for children in the target areas. These findings are consistent with other studies showing similar improvements in COPM scores following occupational therapy intervention for children. Zwicker et al. (2015) observed improved COPM scores for 7-12 year-old children with developmental coordination disorder following Cognitive Orientation to Occupational Performance intervention at a summer camp. Similarly, Ferre et al. (2017) used COPM to measure improvements in performance in bi-manual training for children with cerebral palsy. While the specifics of the intervention and setting were different to the present study, the COPM was sensitive enough to determine when changes were present in perceived performance and satisfaction.
Interestingly, there was no relationship observed between the amount of occupational therapy sessions received (either individual or group) and positive scores on the COPM. This finding may indicate that there is no “ideal” dosage for occupational therapy for children and that the “right” amount of therapy depends on the unique needs of the child and their family (D’Arrigo et al., 2020). Parental engagement and the therapist-parent relationship may be critically important in “tailoring” an occupational therapy services to best fit the needs of children and families. A qualitative study by D’Arrigo et al. (2020) highlighted that engaging with parents was an important component of determining the right “dosage” of occupational therapy in terms of frequency and duration of sessions. If therapy dosage did not fit the needs of the family (too much or too little), this was perceived to negatively impact parent engagement and subsequent therapy outcomes. Parental engagement in occupational therapy is complex, comprising a number of elements including parental expectations of the therapy (D’Arrigo et al., 2020); parental cultural background, health literacy (Smith & Gallego, 2021); and socioeconomic status (Woolfenden et al., 2020). These complexities warrant further investigation in future studies as they may impact occupational therapy outcomes.
Contrasting findings in relation to dosage were observed in a US study by McManus et al. (2019) who reported a clear link between dosage and positive outcomes for young children who received early intervention. Findings may have differed from the current study due to the number of participants in the present study compared with over 400 children reported by McManus and colleagues. It is possible that with more participants in our present study, a significant relationship may have been observed. Differences between McManus’ findings and the present study may also relate to the different study designs, locations and populations and cultural backgrounds, and the different models of health service delivery observed between Australia and the USA. Findings remain inconclusive in terms of the right “dosage” of occupational therapy sessions needed for children to achieve positive parent-rated outcomes and how “dosage” may interact with other important elements for therapy participation. Further work is needed to explore this.
Another important finding is that long wait times were experienced by many children who received a service (around 6 months for most children). Long wait times for therapy services have been commonly observed in other studies. For example, a USA study reported that young children identified as vulnerable were referred to multidisciplinary early intervention services at between 3 months and 3 years of age and waited around 7 months to be seen (Fauth et al., 2023). Long wait times observed may be linked to the high incidence of individual sessions over group sessions observed in the present study. McManus et al. (2019) reported that an increase in frequency and duration of therapy services may contribute to improved outcomes for younger children (90% under 2 years). However, the time-consuming nature of individualised services may exacerbate wait times (Camden et al., 2012) and impact parent engagement with therapy services (D’Arrigo et al., 2020).
It was also observed that children designated as high risk (Priority 1A) waited significantly less time to receive a service. This may indicate that prioritisation within the service is being implemented as intended and services are being provided in a more timely manner to children at greater risk of vulnerability. This observation appears to be in line with recommendations from the Adverse Childhood Experiences Study (ACES) where more timely therapy service provision in early childhood is advocated to reduce the likelihood of poor physical and mental health outcomes in adulthood (Oral et al., 2016). It is not possible to determine how these relatively reduced wait times for high-risk children may have directly influenced long term outcomes for these children or how it may have impacted the wait times of other children.
Limitations and future study
This study used a retrospective file review of one specific service context. This approach has limitations as it relies on the accuracy and availability of the written records. The relatively small sample means that caution must be exercised in drawing any firm conclusions about service effectiveness. Since the duration of service provision was over the course of a year, it is possible that positive changes occurred due to maturation or other supports within the child’s environment including other therapies or pre-school attendance.
Future studies can address this by using a more robust experimental methodology including a matched control group and intention-to-treat analysis to replicate positive findings regarding efficacy. Larger participant numbers would allow for robust efficacy analysis as well as analysis of the factors which may contribute to positive service outcomes such as frequency and duration of intervention, mode/format of delivery, intervention activities, therapist and parent characteristics and wait times. Such studies would be beneficial to guide evidence-based decision making about service provision. A more detailed analysis of goals identified by families and their reasons for choosing these goals was not possible for this study due to the nature of retrospective data collection. This analysis could be conducted in future studies.
Implications for occupational therapy practice
This study offers a number of important implications for occupational therapy practice which can inform service design and delivery of children’s occupational therapy. There is a need to carefully consider the balance between effectiveness and equity in relation to the delivery of occupational therapy services for children. This warrants reflection on intervention format (individual vs. group sessions), noting a preference for individual interventions and the opportunity this provides to “tailor” therapy services for children and families, which may impact outcomes. However, group-based interventions may be appropriate and effective for some children and may facilitate more service efficiency (Henderson et al., 2022). The present study prioritised vulnerable children to receive a service first, mitigating the long wait times that can occur (Camden et al., 2013). Service design and delivery could consider equity considerations in wait times and service prioritisation for vulnerable children, noting they may have increased difficulties accessing health services (Woolfenden et al., 2020).
Our findings do not indicate a correct “dosage” of occupational therapy services for children, and that parent engagement and the therapist-parent relationship are important considerations in deciding on therapy dosage. This highlights the critical importance of family centred care in delivering therapy services (McCarthy & Guerin, 2022). It may be beneficial for clinicians to engage in ongoing routine service evaluation using a measure such as COPM to consider family and child ratings of performance and satisfaction.
Conclusion
This study described community children’s occupational therapy services delivered within a public health service, revealing that services were most commonly delivered in individual format and targeted handwriting and motor skills. Long wait times were observed although children designated as “high risk” waited less time for a service. Analysis with COPM showed statistically significant improvements in parent-rated performance and satisfaction for the children. No relationships were observed between the number of therapy sessions and scores on the COPM. Findings contribute to the evidence base describing occupational therapy for children and offer recommendations for research and practice.
Supplemental Material
Supplemental Material - Descriptive evaluation of community based Children’s occupational therapy services using COPM
Supplemental Material for Descriptive evaluation of community based Children’s occupational therapy services using COPM by Caroline Mills, Stephanie Ritchie Annette Zucco, Kirralee Hazeltine, Jessica Sheaves, and Karen P. Y. Liu in Hong Kong Journal of Occupational Therapy
Footnotes
Acknowledgements
Authors wish to acknowledge and thank the children and families whose data contributed to this paper as well as staff within the health service where this research was conducted.
Author contributors
KL is senior author and designed the overall study, led on SR’s honours supervision, led on data analysis, data interpretation and write up. CM was involved in supervision of SR’s honours work, led on ethical approval, data cleaning of quantitative data and data analysis, interpretation and led on literature reviewing and write up of the manuscript. SR completed this work as part of her honours degree in occupational therapy at Western Sydney University. She led on data collection and was guided in data analysis and initial write up. AZ, KH and JS were involved in study design, data collection, supporting SR in her honours work, data interpretation following analysis and contributed to manuscript write up.
Declaration of conflicting interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: This work was completed as part of the second authors' honours degree at Western Sydney University supervised by the first and last author. Authors 3, 4 and 5 were employed within the health service that was evaluated at the time of the project. Authors KH, AZ and JS were employed in the service where data was collected from. Data analysis was led by CM, SR and KL as part of SR’s honours thesis in Occupational Therapy at Western Sydney University supervised by CM and KL.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical statement
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References
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