Background
The worldwide increase in life expectancy and the growth of the older population has promoted a global public concern for the health and quality of life of older adults throughout the ageing process [
1,
2]. In Taiwan, official statistics on population projections revealed that older adults accounted for more than 14% of the total population in 2018, when Taiwan was classified as ‘an aged society’. It is expected that older adults will account for more than 20% of the Taiwanese population by 2025, when Taiwan will become a ‘super-aged society’ [
3]. These older adults may encounter age-related physical and psychological declines in function and independence, which may increase the burdens on families and the general society. However, older adults can still experience satisfactory ageing with the active management of their health and lifestyles [
4]. For example, incorporating physical and mental activities in everyday life enhances life satisfaction and psychological well-being, and maintaining a healthy diet and appropriate body weight decreases cardiovascular disease in older adults [
5]. To ensure the rights of health and wellness of older adults, the World Health Organization (WHO) proposed that healthy ageing should be promoted and measured scientifically [
6].
The WHO states that ‘healthy ageing’ involves developing and maintaining the functional ability that enables wellbeing in older age [
6‐
8], which can be attained by participating in occupations (i.e., chunks of activities that are cultually and personally meaningful) [
9‐
11]. Evidence has demonstrated that maintaining a greater degree of overall meaningful activity can predict a higher level of healthy ageing, which is indicated by multiple positive outcomes such as reduced mortality; enhanced psychological function, cognitive function and social competence; and improved psychological and physical well-being and health-related quality of life [
12‐
15].
To predict the level of healthy ageing, the assessment of participation in meaningful activities should contain items covering various domains and comprehensive concepts of activity participation. Ageing and occupation-based theories and models such as the Model of Selective Optimization with Compensation [
16], the Life-Span Theory of Control [
17], and the Model of Human Occupation [
18] indicate that older adults may change the meaning they attach to activities over time and develop coping strategies through routine practice and the use of their capacities and resources to successfully participate in activities and maintain well-being. Accordingly, two properties of measures of meaningful activity participation for older adults are suggested: (i) a variety of activity items for personal selection, such as those belonging to the physical, psychosocial and educational domains [
9], and (ii) subjective and objective indicators of meaningful activity participation (i.e., meaningfulness and frequency) [
19]. In addition, to assist in intervention design and outcome measurement for older adults, a measure of activity participation should have two additional properties: (iii) sound psychometric properties and (iv) the capability to predict aspects of healthy ageing such as psychological well-being and health-related quality of life.
A review of existing measures of activity participation revealed that most do not feature the four properties described above. Some measures do not provide various activity items for selection. For example, the Engagement in Meaningful Activities Survey (EMAS) assesses aspects of activity meaning of specific pre-determined activities [
20]. Therefore, the EMAS can neither address which activities are preferred by the individual nor provide information on the meaningfulness of various activities for personal selection and adaptation. Other measures do not use both subjective and objective indicators to assess concepts of activity participation. For example, the modified NPS (Norling, Pettersson, Selander) Interest Checklist [
21] uses subjective measures such as preference, experience, motivation and perceived well-being on leisure activities. With only subjective measures, the modified NPS Checklist cannot provide information on how much time was spent on leisure activity participation. On the other hand, the Activity Card Sort (ACT) [
22] calculates the number of engaged activity items as an objective indicator of activity participation. With only objective measures of activity numbers, the ACT cannot reflect the personal experience of meaningfulness in activity participation. To our knowledge, the Meaningful Activity Participation Assessment (MAPA) is the only measure which contains all the properties required for a comprehensive measurement of meaningful activity participation [
23].
The MAPA is a checklist-type survey consisting of 28 diverse activity items. These items capture the frequency of participation and the meaningfulness of each activity experienced by the individual. The MAPA consists of two separate subscales. The frequency subscale evaluates the amount of time spent on each of the 28 activities (e.g., cultural activities and physical exercise) during the last few months on a 7-category scale from 0 (‘not at all’) to 6 (‘every day’). The meaningfulness subscale evaluates the meaningfulness of each activity on a 5-category scale from 0 (‘not at all meaningful’) to 4 (‘extremely meaningful’). These two sets of ratings are multiplied for each item and then summed to arrive at an individual’s overall perceived meaningful activity participation score. Thus, the total scores range from 0 to 672, with higher scores indicating greater self-perceived meaningful activity participation. The MAPA has been tested on 154 community-dwelling older adults in good health [
11]. The results showed that it is a reliable and valid measure of meaningful activity participation, with excellent test–retest reliability (
r = .84), good internal consistency (α = 0.85), and good convergent validity with measures of psychosocial well-being and health-related quality of life (α = 0.77–0.89; 0.62–0.93). The MAPA can predict several aspects of successful ageing, such as life satisfaction and less depressive symptoms, meaningfulness of engaged activities, life purpose, and the health-related quality of life of the individual [
23].
Given the great benefits of meaningful activity participation to an individual’s ability and function, health, well-being, and quality of life, the need to use assessments of levels of meaningful activity participation in clinical populations has been proposed by health care practitioners in Taiwan [
24,
25]. Accordingly, the present authors have translated the MAPA into Mandarin Chinese and culturally adapted it for people in Taiwan (i.e., the Taiwan version of the MAPA; the T-MAPA) [
26]. Specifically, the activity items, instructions, and response options used in the MAPA can present differently for target populations in specific countries and cultures. Therefore, our translation and cultural adaptation aimed to achieve conceptual, item, semantic, and operational equivalence between the original and adapted versions to ensure that content validity was retained [
27,
28]. We expected that between versions (MAPA and T-MAPA), the measure would have the same relationships to the underlying concept, the items would be equally relevant and acceptable, and the transference of meaning across languages would be appropriate. In addition, the format, instructions, and administration and measurement methods would have the same effects on both populations. Consequently, several activity items in the MAPA were adapted (i.e., merged, divided, or renamed) for the T-MAPA and new activity items were added (e.g., doing household chores, enjoying good food) [
26].
To the present authors’ knowledge, the culturally adapted T-MAPA with adapted and newly added items has been used by health care practitioners and research teams in Taiwan. However, these users lack information on the psychometric properties of the pre-final T-MAPA (i.e., the MAPA adapted for the Taiwanese context but not yet tested for its formal psychometric properties; for detailed information, please refer to the ‘Development of the pre-final MAPA’ subsection under ‘Methods’). A valid T-MAPA could provide practitioners useful information (e.g., predictions of healthy ageing of individuals and measurements of outcomes). Although previous psychometric investigation revealed that the original MAPA can be used to address the level of well-being and health-related quality of life in older adults, several items such as playing games, medical visits, and using public transportation were reported to have less relevance to the whole scale [
23]. With the inclusion of these ‘misfitting’ items and adapted and newly added items, the existing pre-final T-MAPA has not been psychometrically investigated for its utility in practice. To ensure that the strong psychometric properties of the original MAPA have been retained after adaptation, the psychometric properties of the pre-final T-MAPA must be investigated. Therefore, the purposes of this study were to (i) utilize Rasch analysis to determine the formal Taiwan version of the MAPA (the T-MAPA), and (ii) to investigate the psychometric properties of the T-MAPA, including its dimensionality, measurement invariance, item targeting, person reliability, convergent validity and test–retest reliability.
Discussion
This study translated and cross-culturally adapted the original MAPA for use with older adults in Taiwan, utilized Rasch analysis to generate a 28-item T-MAPA, and investigated its psychometric properties. Our study process led us to make several specific choices to ensure that the T-MAPA would be relevant to older adults in Taiwan. With a rigorous 6-stage process of adaptation, a conceptually, semantically, and operationally equivalent and culturally relevant 29-item T-MAPA was produced. Specifically, the cross-culturally adapted T-MAPA has two merits. First, several activity items were added or modified to reflect the cultural preference or contexts of activity participation for Taiwanese older adults. These items were found to contain generally appropriate levels of activity participation and goodness of fit (item measure = −1.61–1.61 logits; infit and outfit MNSQ = 0.54–1.76).
For example, ‘home making/home maintenance’ in the original MAPA was divided into two items and their expressions were changed to ‘doing household chores’ and ‘home repair/maintenance’ because older adults in Taiwan considered ‘home making’ and ‘home maintenance’ as two different activities in terms of content, meaningfulness and frequency of engagement. In addition, changing the expression of the original ‘home making’ to ‘doing household chores’ was considered more easily understandable. ‘Driving’ was modified to ‘using personal vehicles’, which included both driving by oneself and taking taxis or riding in family/friends’ vehicles, since they are commonly used in Taiwan. ‘Medical visits’ was modified to ‘seeking medical assistance’, including rehabilitation, physical or psychological consultation, or Chinese medicine, to present the diversity of effective medical services supported by the inexpensive national health insurance system in Taiwan. ‘Community organization activities’ and ‘volunteer activities’ were combined because they were contained by each other in most situations, and the activities of enjoying good food, board or educational games, and shopping/grocery shopping were included to reflect leisure activities supported by the dense and inexpensive physical contexts of leisure facilities and shops in Taiwan. With generally acceptable fit to the Rasch model, these culturally meaningful items across the recreational, social, mental, and physical dimensions may extend the ability of assessing the participation in various activities of older adults in Mandarin-speaking cultures.
Second, each item was constructed to be easily understandable to individuals by dividing or merging activity items, designating a referential definition and exemplars for each item, and including meaningfulness and frequency subscales in the same item. The merit of these features was supported by the high person reliability (0.86) and the ability of precise estimation of various levels of meaningful activity participation in older adults (small SE of 0.22–0.39 with large test information of 6.57–20.66).
After the Rasch analysis, the 7-category rating subscale for frequency required modification because of the small number of persons responding to categories 1–5 (the frequencies in a month and in a week). The application of the collapsed 4-category frequency and the 5-category meaningfulness ratings for the total T-MAPA resulted in ordered categories and smoothly advancing thresholds (outfit MNSQ = 0.87–1.11; step calibrations = −0.76, 0.01, 0.75), indicating that the response categories of the subscales in each item were appropriate for the utility of the resultant measures. The results demonstrated that our modification solved the problems addressed by older adults in focus groups who had difficulty categorizing personal activity participation between the many different frequencies in the original version.
After the removal of one misfitting item (i.e., pet care activities), the 28-item T-MAPA generally presented a unidimensional construct with satisfactory PCA results, indicating that the 28 items represent a common latent variable which can be used for assessing the overall meaningful activity participation of individuals. The decision to remove the misfitting ‘pet care activities’ and retain the items with borderline fit statistics (i.e., ‘caring for family members’ and ‘prayer/meditation/ancestor worship’) are further discussed.
‘Pet care activities’ in the original MAPA may reflect divergent meaningfulness and frequency of participation in Taiwanese culture. For people in western countries, participating in ‘pet care activities’ may have positive benefits of preventing older adults from social isolation, contributing to better physical and psychological well-being, and being personally meaningful [
61,
62]. However, divergent occupational meanings ascribed to ‘pet care activities’ were found in older adults in Taiwan. In the cognitive debriefing, some of the participants who reported high overall meaningful activity participation in the T-MAPA considered that ‘pet care activities’ was a compulsory ‘job’. Thus, most of the participants responded that the pet care activities were ‘not at all meaningful’ (35.6%) or ‘somewhat meaningful’ (29.5%). The inconsistent responses of the participants to ‘pet care activities’ and the other activities may have caused the misfitting of this item (infit/outfit MNSQ = 2.26/2.32), and thus it was deleted to ensure that the overall scale measured the same construct.
On the other hand, the item ‘caring for family members’, with borderline fit statistics, was found to be very to extremely meaningful for older adults (72.6%), indicating that this item was significant for this population. The presentation of its borderline value of MNSQ (1.65–1.72) can be explained by noting that over half of the sample was below 65 years old (56.8%) and lived with healthy family members without the need for special care (45.9% reported zero frequency of participation). With the consideration of the limited representation of our sample for the whole population and the great significance of ‘caring for family’ for older adults, item 3 was retained to support the content validity of the T-MAPA. However, further testing of this item on another sample with more ‘older’ adults (above 65 years old) is warranted to confirm its fit to the Rasch model.
The item ‘prayer/meditation/ancestor worship’, defined as ‘spiritual activities without relevance to religious belief’, demonstrated some meaningfulness with low frequency of participation (40.4% less than once a month). This can be explained by Taiwanese customs, in which people are more likely to perform religious rituals (item 25 ‘religious activities’ such as chanting scriptures and attending churches for worship) to engage in spiritual related activities and less likely to participate in personal spiritual activities (item 26 ‘Prayer/meditation/ancestor worship’). To test this hypothesis, items 25 and 26 were temporarily merged into one activity item, given that the concept of ‘spirituality’ can contain that of ‘religion’ [
63]. This combination revealed a satisfactory item fit (infit/outfit MNSQ = 1.20/1.21). Further testing of item statistics on the combination of items 25 and 26 in a larger sample is recommended to confirm the adequacy of the two-item combination (religious and spiritual activities) in representing meaningful activity participation.
Although items 2, 6, 10, 22, and 29 exhibited slight DIF, they are important and relevant to older adults’ meaningful activity participation, as they include the aspects of instrumental activities of daily living, social communication, and learning. Whether such bias has substantive implications in person measures was further investigated. Linacre [
47] suggested two strategies for evaluating the real influence of DIF and determining when to adjust for it. First, the DIF impact on person measures can be affected by the length of the test. The adjustment of the criteria of DIF significance by item numbers is practical and has been used previously in another scale validation study [
20]. Accordingly, the absolute DIF value of 0.72–2.00 logits across the education subgroups on items 2, 6, 10, 22, and 29 may have real average impacts of 0.03–0.07 logit bias on a person’s meaningful activity participation in the 28-item T-MAPA. With such small bias, the real impact of DIF on person measures is negligible. Second, to determine when to adjust for DIF, whether the DIF is replicable should be tested when the subgroup is split in a different way. Given the far smaller numbers of persons in education levels 1 and 2 (11.6% and 10.3% respectively) than in other subgroups, the two subgroups were combined into one, and the DIF of each item across the three education subgroups (i.e., < 10, 10–12, and > 12 years) was analyzed. The results showed no significant DIF size across education subgroups for each item (absolute DIF size = 0–0.51). Therefore, the DIF bias found in the previous analysis may have been just an accident of sampling, as it disappeared after regrouping of the sample. Finally, the five items with slight DIF in the first place were retained because the DIF no longer existed after further investigations.
In the inspection of the hierarchy of activity items, several activity items with approximate logit values were found to possess different occupational forms, functions, and contents of meaningfulness. Such item combination can be beneficial in practice. Specifically, each of the activity items with approximate levels of meaningful activity participation in the scale can be used as a complementary occupation in occupational adaptation when an individual’s previous occupation has to be discontinued due to specific disabilities in the ageing process.
Regarding item difficulty, listening to radio/watching TV, using personal vehicles, and doing physical exercise were considered the three most meaningful items of activity participation (item measures = −1.69, −1.61, and −1.44 logits respectively) in Taiwan. Most of the sample reported that they listened to the radio or watched TV every day and felt it moderately to extremely meaningful. This result is consistent with another finding that older adults considered watching TV an important activity in daily living, as it helped them obtain information about what was happening in society and the world, provided entertainment, and produced emotional bonding [
64]. On the other hand, doing physical exercise was also substantively significant and highly participated in by this population for health reasons [
65,
66]. With increasing knowledge about the benefits of physical exercise to physical and mental health, physical exercise has become one of the most popular daily routines for older adults in Taiwan. Another activity, ‘using personal vehicles’, was reported as highly meaningful and frequently engaged in by Taiwanese older adults for several reasons. Using personal vehicles helps individuals to access other activities for physical and mental needs, such as seeking medical assistance, doing physical exercise, enjoying good food, and grocery shopping. It also provides an opportunity for individuals to explore environments for spiritual and social needs, such as travelling and attending cultural activities [
67]. In addition, the unique geographical and environmental features of Taiwan, a small island with short distances between cities, and the lack of dense public transportation networks made older adults prefer to use personal vehicles such as scooters and cars for their transportation [
67].
In contrast, visiting a movie theatre and doing crafts/creative activities were considered less meaningful and less engaged in (item measures = 1.61 and 1.29 logits respectively) for Taiwanese older adults. Older adults may visit movie theatres less frequently because the environment is not friendly to them due to the stairs leading to the seats and low lighting, and also that the movies on the market may not be in harmony with the preferences of older adults. Thus, the frequency of visiting movie theatres was lower than those of other activities in the T-MAPA, although watching films was found to be meaningful to this population. To substitute for their preference of visiting movie theatres in their younger days, some of the older adults in focus groups chose to stay home to watch films (included in ‘radio/TV’). Analysis of the ‘crafts/creative activities’ in the T-MAPA revealed that the ascribed meaningfulness varied, ranging from ‘somewhat to very meaningful’ for older adults; however, this activity was ‘never participated in’ by over half of the sample (59.6%). A possible explanation is that doing crafts/creative activities requires individuals to employ sharp vision, good fine motor and bilateral coordination, and more fluid intelligence, all of which are abilities that decline in older adults [
68,
69]. Therefore, engaging in crafts/creative activities likely became challenging in this population, and the challenges were a deterrent to participation.
Furthermore, the differences between occupations listed in the T-MAPA and the original MAPA reflect culturally specific meanings as well as the temporal and contextual characteristics of occupations. The overall list of meaningful activities in the Taiwan version contains diverse activity items representative of specific subcultures of different generations. For example, the activity items in the T-MAPA range from traditional to contemporary (e.g., writing letters/cards to e-mail/e-cards, visiting a movie theatre to watching TV/films, reading books to e-books, doing household chores/cooking to enjoying good food). Specifically, the diversity of occupations listed for older adults reflects the evolution of the population aged 55–87 years in responding to the dramatic cultural and environmental changes in this era. Such diverse occupations provided the treasures inherent in human culture, allowing older adults nowadays to adapt to life challenges and produce positive health-related outcomes rapidly and effectively.
This study has limitations. The sample was composed of healthy older adults in Taiwan, so the generalizability of our psychometric findings to populations with other characteristics may be limited. For instance, the form, function, and meaning of item contents, and the overall meaning and frequency of activity participation, may be different for persons who have health conditions such as stroke or schizophrenia or those who belong to a different age group. In this regard, we recommend that the items in the T-MAPA be inspected for possible modification of the item contents, followed by psychometric evaluations, before the T-MAPA is applied to other populations. To extend the clinical utility of the scale, future studies are warranted to examine the optimal cut-off points of function/dysfunction in people with specific health conditions. Specifically, no information on the levels of meaningful activity participation among the older population has been established in the present study. Therefore, one cannot conclude that the lower scores of such individuals obtained in the assessment of the T-MAPA indicate substantially insufficient meaningful activity participation, and the precision of planning interventions can be negotiated. For example, scores distinguishing the levels of meaningful activity participation between older adults with and without depression should be established to determine the level of dysfunction for intervention planning in people with depression.
This 28-item T-MAPA has several important clinical implications. First, it requires only 10 to 20 min for administration, which allows older adults with poor tolerance or short attention spans to complete the whole scale without much difficulty. This field-tested and adapted scale is client-centred and can be applied with verbal or written instructions. It is also administrator-friendly with the establishment of a standardized administration manual. Moreover, this scale is suitable for older adults in Taiwan of any education level, as the study sample included individuals with elementary school-level education or below. With the inclusion of new culturally relevant items presenting small SE with large TIF, the T-MAPA provides precise estimates of various levels of meaningful activity participation in this sample. The use of the Rasch transformed score allows the application of more powerful parametric statistics to calculate and compare the assessed results. Another prominent benefit of this Rasch-calibrated T-MAPA is the construction of relative ordering of each activity item. It provides a reference for gradual interventions and the occupational adaptation process. For example, by initially introducing items reflecting lower levels of meaningful activity participation (e.g., physical exercise, using personal vehicles, and radio/TV), individuals with major difficulty in overall meaningful activity participation may benefit by acquiring adaptive skills for activity participation.
In conclusion, the 28-item T- MAPA introduces several innovations to the original version that make this assessment more suitable for the population in Taiwan (or those affiliated with Greater Chinese cultures). After a rigorous 6-stage cross-cultural adaptation process, the 28-item T-MAPA had good psychometric properties, including effective category function, unidimensionality, measurement invariance, acceptable item targeting, good person reliability, estimation precision, and test–retest reliability (with negligible measurement error), as well as confirmed convergent validity with psychological well-being and health. The T-MAPA may be applicable as a valid assessment for measuring meaningful activity participation in older adults, planning interventions, measuring outcomes, and predicting healthy ageing.