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\begin{document}

\title{Occupation-based practice: Developing a new instrument}



\author[1]{Ilande Vorster}%
\author[2]{Helen Buchanan}%
\author[3]{Karen Grimmer}%
\affil[1]{Affiliation not available}%
\affil[2]{University of Cape Town Faculty of Health Sciences}%
\affil[3]{Philosophy and Practice of implementation of evidence}%


\vspace{-1em}



  
  \date{June 10, 2024}


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\selectlanguage{english}
\begin{abstract}
Rationale and objective: Occupation-based practice (OBP) is a treatment
approach unique to occupational therapy. It harnesses the power of
occupation to achieve health and well-being. Most hand therapists are
occupational therapists, however, current hand therapy treatment methods
are component-based, focussing on physical impairments. This is despite
an emerging body of evidence that supports the effectiveness of OBP with
hand conditions. To explore the use of OBP in hand therapy, the
knowledge, attitudes and practices (KAP) of South African occupational
therapists towards OBP needed to be first established. There was no
contextually-relevant instrument for this, thus this paper reports on
the development processes of a new instrument to capture KAP in OBP in
South African hand therapists. Method: Questionnaire development
followed the Burns et al (2008) methodology. Items were identified
following a comprehensive literature search. Face and content validity,
clinical utility, and validation of the subsequent Afrikaans translation
were undertaken by two purposively-selected sets of participants
(experts and peers). Data collection involved cognitive interviewing,
iterative email correspondence, face-to-face discussions, and member
checking. Final adjustments to questionnaire wording were made through
consensus discussion between the first and second authors. Results: Four
therapists participated. Seventy-nine questionnaire items were retained,
with three items being removed as they were unclear, or did not measure
constructs appropriately for context. The final survey instrument had
face and content validity and consisted of 63 KAP items and 16
demographic questions. Conclusion: This is believed to be the first
instrument designed to capture valid information on KAP in OBP in hand
therapy in South Africa. It will assist in identifying gaps in practice
quality, and underpin design of effective strategies for education
about, and implementation of, OBP within hand therapy. The instrument is
suitable for adaptation to other fields of occupational therapy practice
in South Africa, and internationally.%
\end{abstract}%



\sloppy


Ilande Vorster, Helen Buchanan, Karen Grimmer

\textbf{Keywords}

occupation-based practice; knowledge, attitudes and practices; survey
development; occupational therapy; hand therapy

\textbf{1 INTRODUCTION}

Occupation-based practice (OBP) is a treatment approach which
encompasses the therapeutic use of occupation.\textsuperscript{1,2.} It
is used mostly by occupational therapists.\textsuperscript{1,2} OBP
aligns with the profession's philosophical foundation, which is guided
by the belief that health and well-being are strongly associated with
the occupations people perform.\textsuperscript{3} In South Africa, most
hand therapists are occupational therapists.\textsuperscript{4} Due to
the dearth of occupational therapists in South Africa and the resultant
demand to manage consistently large caseloads, it is essential that
therapists are equipped to provide hand-injured patients with the most
effective, cost-efficient care. Evidence-based practice is proposed as
one way of ensuring that optimum care is delivered, and received, at
every healthcare contact.\textsuperscript{5}

Hand injuries are common and often catastrophic in South Africa due to
poor work conditions and high rates of road traffic accidents and
interpersonal violence.\textsuperscript{6} Hand therapy in South Africa
is potentially complex because of the range of occupations which exist
and injuries which can occur; occupational therapists therefore need to
be conversant with current evidence in order to provide the most
effective, and cost-efficient, care.

The strong presence of occupational therapists in the hand therapy arena
should equate to an occupational focus in practice and research. However
this does not appear to be the case. A mapping review of hand therapy
publications over a ten year period exploring the alignment of evidence
underpinning practice, found that hand therapy research is dominated by
exercise and orthotic interventions focusing on specific
diagnoses.\textsuperscript{9} Similarly, surveys conducted in Australia,
Israel and the USA\textsuperscript{8,9,10}found that intervention and
research focussed on body structures and functions. The same trend was
shown in a recent South African study which found that hand therapy
assessments addressing activity and participation (occupation) were used
infrequently.\textsuperscript{11}

OBP is supported by a growing body of evidence that suggests that it is
more effective than component-based
practice.\textsuperscript{3,21,25,41,42,43,44} Therefore, identifying
gaps in knowledge, attitudes and/or practices is essential in the
development of strategies for effective interventions. Our intention was
to obtain a comprehensive understanding of how occupational therapists
were implementing OBP in South Africa, when dealing with injured hands.
This knowledge could assist in strengthening the quality of occupational
therapy hand rehabilitation provided in South Africa (in terms of
improved occupational performance and occupational engagement outcomes).
In order to determine this, an instrument that could assess these
components was required. However, an extensive literature search found
no comprehensive survey instrument from any country which assessed
knowledge, attitudes and practices (KAP) about OBP. The main emphasis in
the literature on OBP appeared to be on individual aspects of OBP such
as knowledge\textsuperscript{12,13},
attitudes/perceptions\textsuperscript{14,15,16} and practices, with a
specific focus on either assessment or treatment
alone.\textsuperscript{9,11} Thus there was a knowledge gap in terms of
the availability of a comprehensive survey instrument to measure
occupational therapists' KAP in OBP.

This article reports on the development of a new instrument to measure
the KAP of hand therapists using OBP, relevant to South African
contexts.

\textbf{2 METHODOLOGY}

\textbf{2.1 Ethics}

The study was approved by University of Cape Town Human Research Ethics
Committee (HREC REF: 208/2018) in May 2018.

\textbf{2.2 Reporting framework}

This article is reported using the STROBE checklist.\textsuperscript{17}

\textbf{2.3 Study design}

This was an instrument development and validation study based on
methodology described by Burns et al.\textsuperscript{18} After
developing the draft instrument from a literature search, psychometric
properties of face and content validity were tested, and clinical
utility was addressed. An Afrikaans translation of the instrument was
subsequently produced and validated.

\textbf{2.4 Validating the instrument throughout its development}

Methods included recruiting panels of expert and peer occupational
therapists, and engaging them with cognitive interviewing, iterative
email correspondence, face-to-face discussions, and member checking.

\textbf{2.5 Setting}

South African occupational therapy practice.

\textbf{2.6 Participants}

The study included two purposively selected sets of participants. The
first group comprised occupational therapy experts with more than ten
years of experience in hand therapy, who were employed at a tertiary
education institution in South Africa, and had published in the field.
They had extensive knowledge of OBP and experience in survey
methodology. The second group consisted of peers who had, or were
completing, a post-graduate degree in occupational therapy, and had
worked in the field of hand therapy for more than five years, but were
no longer actively practicing. This group was recruited so as not to
reduce the potential pool of survey participants for a national study to
determine KAP nationally.

\textbf{2.7 Recruitment}

Due to the small pool of experts in this area in South Africa, only two
people met the inclusion criteria. Both were known to the authors and
were recruited by email invitation (April 2018). Peers were recruited by
personal invitation based on convenience sampling, namely they were
known to the first author and could be readily recruited. All
participants were recruited simultaneously.

\textbf{2.8 Bias}

Expert opinion will always be influenced by biases such as personal
experience, preferences, workplace exposure and relationships with the
researchers.\textsuperscript{19} Attempts were made to minimise bias by
recruiting participants who reflected some diversity in terms of
practice area, research interest, language and experience in
occupation-based hand therapy. We also requested participants to be
honest in their responses, however, we acknowledge that expert bias may
still have been present due to the small pool of experts available in
this area.

\textbf{2.9 Process of instrument development}

Established principles of survey design were
applied.\textsuperscript{18} The steps taken to develop and validate the
survey instrument are outlined in Table 1.

{[}Place Table 1 here{]}

\textbf{2.9.1 Step 1: Item generation}

Before developing the questions, the constructs that we intended to
measure required identification and definition. These included KAP, as
well as demographic questions. A database search was undertaken to
identify aspects of OBP and KAP that should be included in the
questionnaire. Electronic searches of CINAHL (Cumulative Index to
Nursing and Allied Health Literature) via EBSCOhost, Pubmed and Google
Scholar were conducted between July 2017 and March 2018 using the search
string hand therap* AND (occupation* OR occupation based practice* OR
occupation based intervention OR occupation as a means and occupation as
an end). These keywords were chosen based on the different operational
definitions for the concept of OBP used in previous studies. Papers had
to be in English and published from 2000 onwards. A total of 26 papers
were retrieved during the database search and used in the development of
the survey items.

As no existing questionnaires measuring KAP related to OBP in hand
therapy had been identified in the first database search, studies
investigating KAP as single constructs in hand therapy literature, or in
related areas, were sought, and relevant items were identified. Key
points were extracted from the definitions of each construct, and
relevant items were identified and
extracted\textsuperscript{8,9,20,21,22,23,24} (see Table 2). As the
literature on occupation-based hand therapy predominantly focussed on
barriers and facilitators,\textsuperscript{21,24,25} these aspects were
included in the questionnaire to obtain information on practice
influences that could be compared across other studies. Table 2 outlines
the questionnaire constructs with the key points extracted from their
definitions, and the studies from which the information was obtained.

{[}Place Table 2 here{]}

A table of specifications was developed by listing each construct (KAP
and influences) with all related key points on the vertical axis and
applicable themes related to OBP on the horizontal axis. Each cell was
then summarised by a draft question/statement that linked with an aspect
of the construct (on the vertical axis) with the theme (on the
horizontal axis). Statement wording was additionally informed through
personal and professional experience, until saturation was
reached.\textsuperscript{18} Survey items were then generated from the
items listed in the table of specifications.

\textbf{2.9.2 Step 2: Item wording}

Each item addressed a single construct, and was worded in a neutral,
understandable tone.\textsuperscript{18} Similar items for each
construct were reworded either positively or negatively to reduce bias
stemming from participants answering in a particular
pattern,\textsuperscript{31} and to improve internal consistency. We
attempted to keep the wording and formatting simple and understandable
to prevent misinterpretation and potential measurement
error.\textsuperscript{32}

Items were based on reflections of occurrences within the last month to
prevent respondents from being unduly influenced by incidents that may
not have reflected their usual practice. Similar items were worded in a
positive and negative manner to assess the consistency of
responses\textsuperscript{33.} This mechanism enhances internal
consistency as closely worded items can yield a higher inter-item
correlation.\textsuperscript{34}

\textbf{2.9.3 Step 3: Responses}

Five-point Likert scales (ranging from strongly disagree to strongly
agree) were chosen to rate most items (n=48) as these provide an
``ambivalent'' midpoint and are sensitive and
reliable.\textsuperscript{35,36} Five-point scales also have a
familiarity factor contributing to ease of completion. Four-point scales
with time-based responses (always, often/mostly, sometimes/rarely,
never) were applied to the eight questions in the practice habits
section as items referred to frequency of habits related to OBP.
Open-ended questions were included at the end of each survey section, to
capture other comments that had not been addressed in the scaled
questions.

\textbf{2.9.4 Step 4: Psychometric property testing}

\begin{enumerate}
\tightlist
\item
  \emph{Preliminary discussions} : Two authors (IV, HB) discussed the
  item list and identified redundant items for removal.
\item
  \emph{Validation approach} : Prompts based on Patrick et
  al.\textsuperscript{37}, Burton and Mazerolle\textsuperscript{34} and
  Heale and Twycross\textsuperscript{38} were developed to seek input on
  the draft instrument questions from the expert and peer panels (see
  Table 3). The intent of these questions was to seek input from these
  participants on phrasing, appropriateness of the questions, flow of
  the survey, layout, sequencing and timing, intended meanings of items
  to assess whether responses agreed with opinions and nuances in the
  understanding of terminology and concepts.\textsuperscript{33}
\end{enumerate}

{[}Place Table 3 here{]}

\begin{enumerate}
\tightlist
\item
  \emph{Dissemination} : The expert panel members were emailed a cover
  letter, a link to the survey set up on GoogleForms, and a Microsoft
  Word document containing the questions in Table 3, set up in table
  format, hereafter referred to as the ``feedback document''. An
  additional opportunity for comment on each item was provided. The peer
  members completed the draft questionnaire independently in the
  presence of the first author. This was timed to provide information on
  clinical utility.
\item
  \emph{Cognitive interviews} : After completing the questionnaire, the
  peers were individually interviewed by the first author, using the
  questions in Table 3 as prompts and using concurrent verbal
  probing.\textsuperscript{39} Cognitive
  interviews\textsuperscript{34,37,39} are a method of verifying written
  feedback on phrasing, appropriateness of the questions and flow of the
  survey.
\item
  \emph{Data collection} : The experts in the validation group returned
  the Microsoft Word feedback document by email to the principal author
  (IV) with their feedback addressing each question in Table 3, for each
  item in the draft survey instrument. These responses were aggregated,
  with the peer responses, into a master document in which respondents
  were not able to be identified by the second author (HB).
\item
  \emph{Researcher oversight} : The collated responses were discussed by
  IV and HB, to determine actions for each item. Items for which the
  validation group was in complete agreement were accepted ``as is''.
  Items with suggestions for changes to wording were modified where the
  change made sense. These changes were made irrespective of the number
  of people who suggested them. Redundant items were identified and
  removed to reduce the likelihood of non-response due to respondent
  burden.\textsuperscript{23,40} Suggestions for changes in formatting
  within the survey instrument were considered, and decisions were made
  based on the capabilities of GoogleForms, and respondent burden with
  regards to length of questionnaire and ease of use.
\end{enumerate}

\textbf{2.9.4.1 Outcome}

Feedback obtained from the experts and peers was incorporated into the
English-language questionnaire to include only the most representative
items, and this version was finalised.

\par\null

\textbf{2.9.5 Step 5: Translation into Afrikaans}

As English and Afrikaans are the only mediums of instruction for
occupational therapy university education across South Africa, potential
participants would be expected to be competent in at least one of these
languages, and thus familiar with the terms and concepts used. The
questionnaire was therefore translated into Afrikaans to ensure that the
occupational therapy respondents would not be discriminated against by
written language. The following steps were taken:

\begin{enumerate}
\tightlist
\item
  The first author (bilingual in these languages) completed the initial
  translation from English to Afrikaans.
\item
  The initial translation was checked for grammatical errors by two
  independent Afrikaans-first-language peers identified by the first
  author. Where errors were identified, corrections were made.
\item
  One expert in the validation phase of the survey, an
  Afrikaans-first-language speaker, who was already familiar with the
  English version was requested to comment on the Afrikaans version.
  Further grammatical and terminological corrections were made to
  produce the final Afrikaans version of the survey.
\end{enumerate}

\textbf{3 RESULTS}

\textbf{3.1 Expert and peer validation groups}

Four participants were recruited and all participated (two experts, two
peers).

\textbf{3.2 Item retention}

There were 85 items in the initial draft of the questionnaire, of which
three items were removed at the preliminary discussion step between two
of the authors (IV and HB). Thus 82 items were tested in the validation
steps, and 79 items were retained. The redundant items were identified
as being too similar to other questions, unclear, or not measuring the
construct within which it was placed.

\textbf{3.3 Modifications to the remaining items}

Considering the feedback from the experts and peers:

\begin{itemize}
\tightlist
\item
  There was a request to add an option for an open-ended response after
  every question. However, GoogleForms does not provide for two methods
  of response options, i.e. multiple choice and an open-ended answer per
  item. Adding comment options would thus have required adding another
  item for each question, which would have doubled the length of the
  survey and risked non-response or premature abandonment. It was
  therefore decided that one open-ended comment after each section was
  sufficient.
\item
  A recommendation to add definitions for the concepts ``occupation as a
  means'' and ``occupation as an end'' was received with the rationale
  that the older generation of therapists may have been unfamiliar with
  the terms.
\item
  The practice setting list of options was amended to include
  specialised rehabilitation settings.
\item
  An item was included for respondents to add assessments to obtain an
  occupational profile of the patient.
\item
  Question wording for item 75, ``Using occupation in treatment makes me
  stand out from other professionals'', was changed to ``\ldots{} makes
  my therapy unique/distinct from other professionals'' to ensure the
  neutrality of the sentence.
\item
  Grammatical corrections, adding examples to improve clarity, changing
  the order of questions to group similar questions together and changes
  to response formats (including drop-down menus/changing wording)
  enhanced the questionnaire.
\item
  Wording was changed from ``intervention'' to ``practice'' to encompass
  the whole occupational therapy process.
\end{itemize}

\textbf{3.4 Final questionnaire}

The final questionnaire consists of 63 KAP items and 16 demographic
questions (a total of 79 items). The instrument is outlined in Table 4
and the full survey (English and Afrikaans versions) is available from
the first author on request. Based on the suggested changes made
throughout the validation process, both expert and peer groups agreed
that the items had face and content validity.

{[}Place Table 4 here{]}

\textbf{4 DISCUSSION}

This paper reports, to the best of our knowledge, the first valid survey
on KAP in occupation-based hand therapy, for hand therapists. We believe
that the sound psychometric properties of this survey offer promise for
future research and interventions in this area.

The methodology used to develop and validate this survey was rigorous,
iterative and used well-defined stages and processes to create the
initial item list, identify appropriate experts and peers to review the
instrument, consider it in terms of validity, utility and respondent
burden, make subsequent modifications to ensure optimum impact, and then
translate and verify it in Afrikaans.

Ensuring that South African hand therapists are competent and embrace
evidence-based practice is an essential element of professional
quality\textsuperscript{5}. Evidence-based practice shows that OBP has
proven benefits in the treatment of a hand-related
condition\textsuperscript{3,21,25,41,42,43,44}. The survey can thus be
used as a tool to plot practice trends to identify areas where
occupational therapists treating hand-related conditions can incorporate
OBP. This questionnaire should be of interest to South African hand
therapy educators delivering undergraduate and postgraduate programmes
as a tool to identify knowledge and attitudes towards OBP to inform
educational endeavours to promote the use of OBP. This questionnaire may
also be relevant for hand therapy educators internationally as the
initial items were derived from international literature, and no local
contextual issues were raised during the validation process. Moreover,
the questionnaire items lend themselves to adaptation to other fields of
practice, as KAP is a universal concern.

There are potential limitations in the process undertaken for
questionnaire development and its validation:

\begin{itemize}
\tightlist
\item
  The questionnaire items were identified from a comprehensive
  literature search, however, as with all searches, there is the
  possibility that important information was overlooked and relevant
  items were not included. Furthermore, as accurate records were not
  kept of the search process, there is no evidence that all relevant
  literature was captured. However, as none of the validation group
  identified new items, we believe that the item list is comprehensive.
\item
  Bias may have been introduced by the purposive sampling of experts and
  peers in the validation group. All participants were of the same race,
  and from relatively similar backgrounds. They therefore may not have
  brought important knowledge about culture and race to the discussions,
  in ways that may have provided a different lens to capture information
  on KAP in occupation-based hand therapy in South Africa. This was
  partially unavoidable due to the limited pool of occupational therapy
  academics with expertise in the field of hand therapy in South Africa.
  The peer group could however have been more diverse and larger; this
  is a serious limitation that should be addressed in further validation
  studies of this instrument.
\end{itemize}

A pilot study was not conducted, to test for utility, to determine
whether there were further redundant items, or to consider issues of
intra-rater reliability over time. KAP contains attributes that may
change between two test periods, depending on participant exposure to
learning opportunities in the interim period.\textsuperscript{18} The
decision not to conduct a pilot study was made because the sample of
hand therapists in South Africa is relatively small, and the intention
of the eventual application of this questionnaire was to capture KAP
nationally. Conducting a pilot study would thus have reduced the
available pool of respondents for a larger national survey. The
questionnaire development and validation process could thus be
criticised as no information on its wider application exists.

\textbf{5 CONCLUSION}

This paper presents the process of developing the first evidence-based
validated questionnaire designed to capture KAP in occupation-based hand
therapy. Whilst it was developed in South Africa, and is therefore
relevant to South African contexts, it could have international
applicability for occupational hand therapy, and could also be applied
to other types of occupational therapy practice. Future testing would be
required to test its applicability and comprehensiveness, in other
settings.

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\textbf{ACKNOWLEDGEMENTS}

This article was funded through a Postgraduate Publication Incentive
Award from the Health Sciences Faculty Research Committee, University of
Cape Town.

\textbf{CONFLICT OF INTEREST}

Authors declare no conflict of interest.

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