Abstract
The study findings support the need for and use of meaningful activities to support well-being and health for adults with low income. Occupational therapy practitioners can use measures such as the Engagement in Meaningful Activities Survey (EMAS) to strategically infuse aspects of meaning that promote engagement and foster well-being.
Low income and poverty remain a sizable challenge in the United States. The coronavirus disease 2019 (COVID-19) pandemic has exacerbated poverty across all major racial groups except for Blacks, who continue to have the highest poverty rate at 19.5% (Shrider et al., 2021). Adults with low income are more likely to experience higher mortality, health disparities, and physical and mental health challenges (Chokshi, 2018). On the basis of data from 2001 to 2014, Chetty et al. (2016) reported that, after adjusting for age and race, men and women in the bottom 1% of income distribution had an expected age at death of 14.6 yr and 10.1 yr earlier, respectively, than their counterparts in the top 1%. Adults from low-income versus affluent households are 3 times more likely to have limitations in bathing and dressing tasks because of chronic illness (Chokshi, 2018). Limited exposure to and engagement in basic activities may also perpetuate health disparities.
The prevalence of mental health challenges is also greater for adults with low income and impoverishment when compared with the larger population (Cheng et al., 2016). Adults with low income focus on meeting basic needs and addressing “in the moment” issues, which hinders their engagement in activities that develop the life skills required to participate successfully in society and move out of poverty. These day-to-day, stress-inducing challenges are linked to decreased well-being (Cheng et al., 2016). The pervasive nature of health disparities associated with low income prompt continued efforts to uncover mechanisms that promote health and well-being within this vulnerable population. Larger efforts to address the social and economic determinants of health remain critical (Singu et al., 2020); in addition, although some social factors, such as housing and education, are difficult to influence, engagement in meaningful activity is malleable and can be used to enhance health when other factors are fixed (Ciro & Smith, 2015).
Meaningful engagement is a neglected aspect of positive functioning within the model of psychological well-being (Ryff, 2014). Meaning is an essential component of occupation; is central to the processes and outcomes of occupational therapy; and promotes and maintains physical, spiritual, and mental health (American Occupational Therapy Association, 2020). Hammell (2004) has suggested that researchers should investigate the meaning ascribed to what people do to better understand how the act of doing affects health and well-being. The limited empirical research in this area may be because of the abstract and dynamic nature of meaning and meaningful engagement.
The development (Goldberg et al., 2002) and validation (Eakman, 2012) of the Engagement in Meaningful Activities Survey (EMAS; Eakman, 2012) has enabled researchers to empirically investigate the influence of meaningful engagement on health constructs. Engagement in meaningful activities contributes to changes in basic psychological needs fulfillment and changes in meaning in life (Eakman, 2014). Kinney et al. (2020) expanded these investigations and explored the mediating influence of meaningful activity, coping ability, and social support on participation for community-based veterans attending college. These findings provide support for the part that engaging in meaningful activities plays in meaning in life; however, much of this work has focused on college students. Research involving more diverse samples can expand the understanding of how this important construct contributes to or maintains well-being.
In this study, the first of its kind, we examined whether engagement in meaningful activities uniquely contributes to well-being among adults with low income after controlling for demographic variables. We hypothesized that meaningful engagement would be the strongest predictor of psychological well-being among adults with low income.
Method
Design
In this cross-sectional correlational study, we explored the constructs of meaningful engagement, well-being, and time use. Participants were included if they were age 18 yr or older and could understand and read English. The University of Toledo institutional review board approved this study.
Procedure
We recruited 262 participants using flyers and word of mouth from various community locations within a midsized metropolitan area in northwest Ohio. Recruitment occurred in two phases and lasted 18 mo. In Phase 1, we recruited at local agencies serving adults with low income. Participants were provided a data collection packet that included a demographic questionnaire, the EMAS, the World Health Organization–5 Well-Being Index (WHO–5; WHO, 1998), and an Occupational Time Use Survey created for this study (data not reported). Participants received a $10 gift card. In Phase 2, recruitment shifted to a local library and university union hall. Participants submitted an email address for a chance to win a $50 gift card. The data for Phases 1 and 2 were combined.
Measures
Engagement in Meaningful Activities Survey
The EMAS is a 12-item questionnaire used to determine the meaningfulness of day-to-day activities (Goldberg et al., 2002). Participants indicate the answer that best describes the degree to which each statement is true on a 4-point scale ranging from 1 (rarely) to 4 (always; Eakman, 2012). Total scores range between 0 and 48, with a higher score indicating a higher degree of meaningful engagement. The EMAS is a valid tool for evaluating meaningfulness (Eakman, 2012). The survey has demonstrated acceptable test–retest reliability (r = .71) and good internal consistency (α = .88) in a sample of college students (Eakman, 2011).
World Health Organization–5 Well-Being Index
The WHO–5 is used to determine psychological well-being (Bech, 2004). The five statements in the WHO–5 are rated on a 6-point Likert scale, ranging from 0 (none of the time) to 5 (all of the time), to indicate the participants’ perceptions of their well-being. Higher scores indicate higher well-being (Bech et al., 2018). All items within the scale are positively framed to assess a state of psychological well-being rather than measure symptoms (Bech et al., 2018). Demographic data—including age, gender, ethnicity, relationship status, number of children, education level, income, and employment status—were also collected.
Data Analysis
Descriptive statistics were examined for all variables followed by computation of a Pearson correlation between the EMAS and WHO–5. Two consecutive multiple linear regression analyses were conducted to answer the research question. Model 1 included the following covariates: age, gender, ethnicity, annual income, education level, and marital status. Meaningful engagement (EMAS) was added to Model 2. The difference in R 2 values between the two models indicates the unique relationship between meaningful engagement and well-being after controlling for demographic variables. We completed all analyses using IBM SPSS Statistics (Version 23).
Results
We identified adults with low income in our sample by conducting a cross-tabulation using annual income range and the number of people living in the household. To reduce the risk of bias, we compared the data with the U.S. 2021 poverty threshold (U.S. Department of Health and Human Services, 2021) and classified participants living at or below 200% poverty as low income. Annual income data were collected as a range, and participants were included if the 200% poverty threshold for the number of people living in household fell within that income range. We excluded 9 participants with an annual income of $50,000 to $99,000 to decrease inclusion errors because of the wide income range. We included 186 participants in this analysis.
Participants mean age was 42 yr (SD = 17.4); in addition, participants were primarily female (69.4%), White (45.7%), and single (77.8%; Table 1). Participants reported a mean EMAS score of 35 (SD = 7.4), indicating moderate meaningful engagement (Eakman, 2012), and a well-being score of 15.4 (SD = 5.6). A WHO–5 raw score of ≤12 has been used as an indicator for further assessment and a moderate need for treatment (Bech et al., 2018).
Descriptive Data for the Study Participants (N = 186)
Note. GED = General Educational Development.
The n values total to 185 because of missing responses.
The relationship between meaningful engagement and psychological well-being was moderate (r = .52, p ≤ .05). Overall, meaningful engagement and demographic variables explained 27% of the variance in psychological well-being among adults with low income (Table 2). Of this 27%, meaningful engagement alone explained 25% of the variance in well-being on the basis of the R 2 value change from Model 1 (without EMAS as a covariate), R 2 = .02, F(6, 165) = .439, p = .85, to Model 2 (with EMAS as a covariate), R 2 = .27, F(7, 164) = 8.75, p < .001. On the basis of the standardized β values in Model 2, meaningful engagement (β = .52) was the strongest predictor of well-being relative to the demographic covariates in the model (−.01 to −.03)
Multiple Linear Regressions (N = 186)
Note. ΔR 2 = .26, ΔF(1, 164) = 57.76, p ≤ .001. Adj = adjusted; NA = not applicable.
Discussion
The findings support the hypothesis that adults with low income connect engagement in meaningful activities to increased well-being. Moreover, engaging in meaningful activities rather than personal attributes, such as annual income or education level, was the sole significant contributor to well-being within the regression model. These results add to the evidence that the meaning associated with doing or performing is an important contributor to well-being, highlighting the importance of meaning as an aspect of occupation (Roberts & Bannigan, 2018).
Research investigating the influence of meaningful engagement on well-being is important because it helps substantiate the utility of meaningful engagement in occupational therapy practice. In a study conducted with veterans, another vulnerable population, Kinney et al. (2020) found meaningful activity to be the most significant mediator between participation and life meaning and life satisfaction. In our study, the moderate relationship between meaningful engagement and well-being and the strength of the engagement as a predictor of well-being was present even when the degree of well-being across the sample appeared compromised. Bech et al. (2018) found that WHO–5 scores ≤12 indicate a moderate need for treatment. The mean WHO–5 score in this sample was 15.4 (SD = 5.6), with 30% of the sample having a raw score of ≤12. Our findings emphasize the potential role that meaningful engagement may play in addressing well-being for adults with low income.
Gutman (2021) provided a rationale and evidence for occupational therapy’s role in working with marginalized populations. Many adults with low income demonstrate knowledge gaps in the basic life skills needed to obtain a job and prevent health issues. Engagement in meaningful activities offers a means for people to experience competence, satisfaction, altruism, and achievement as well as to demonstrate personal values and love for others (Eakman, 2014). Programs for adults with low income that use meaningful occupations can promote self-sufficiency and decrease financial insecurity (Gutman, 2021). Efforts to address the challenges associated with low income to enhance well-being and quality of life need to focus on increasing access to what a person can do and foster the meaning within those activities.
Schmelzer and Leto (2018) used participatory action research to develop and implement an occupation-based program addressing food insecurity for adults living in poverty, increasing participants’ ability to manage food resources. Programs such as this one demonstrate the distinct value of sculpting the meaning within the doing or performance of an activity. In addition, they highlight the individualized experience of meaning and the need for ideographic measures of engagement in meaningful activities to construct occupation-based interventions (Hooker et al., 2020). The evidence supporting the use of meaningful engagement as a mediator of change in basic psychological needs and participation is growing (Eakman, 2014; Kinney et al., 2020). The results of this study provide further empirical evidence of meaningful engagement as a strong contributor to well-being for a marginalized population in need of occupational therapy services.
Limitations and Future Directions
This study is not without limitations. The cross-sectional study design precludes any causal inference. The individualized nature of meaningful engagement and its transactional relationship with the environment, and the fact that data were collected from a midsized Midwest city, hinder the generalizability of the findings. Likewise, research assessing the validity and reliability of the EMAS is limited to college students and well older adults. In addition, participants were self-selected, and the survey categories for annual income data included unequal ranges, potentially affecting the contribution of this factor. Finally, although the use of a regression model was appropriate for the research question, it may have minimized the impact of individual elements within the model. Additional research that further dissects social determinants of health and considers the multidimensional nature of poverty or low income and meaningful engagement as contributors to well-being is needed.
Implications for Occupational Therapy Practice
This study has the following implications for occupational therapy practice: Exploring aspects of meaning with the EMAS may provide clinicians with tangible insights into the ideographic nature of meaningful engagement and enhance its utility in practice. Incorporating the meaning in activity engagement during interventions may enhance well-being.
Conclusion
The dimensions of meaning that influence participation are complex and powerful contributors to well-being. This study’s findings support the need for meaningful engagement for adults with low income and the distinct value that occupational therapy services can provide.
Footnotes
Acknowledgments
This study was funded by Laura Schmelzer’s start-up funds. The research team acknowledges the study participants for their willingness to share their insights and for their time and effort.