The measurement properties of the model of human occupation screening tool and implications for practice.
In addition to the challenge of designing and implementing more occupation-focused practice, therapists face other contemporary expectations for practice. Firstly, there have been calls for client-centred practice that embraces a philosophy of respect and partnership with clients (Law, 1998). The client-centred approach recognises the need to understand the motives and unique circumstances of each client (Kielhofner, 2002). Secondly, the health profession council (HPC, 2004) has also detailed the need for therapists to "use the established theories, models, frameworks and concepts of occupational therapy" (p. 11). Being able to develop a theoretically driven understanding Kramer, L. Summerfield Mann, and E. Duncan. of a client's occupational circumstances is the sign of a profession (Curry & Wergin, 1993; Sibeon, 1991). A further consideration is the burden of documentation for therapists in the context of increasing demands for productivity (Hagedorn, 1995). Finally, therapists are urged to engage in evidence-based practice that uses the highest quality knowledge to guide practice decisions (HEFCE, 2001; Scottish Exec, 2002; Creek & Ilott, 2002).
Taken together, these expectations create multiple demands in the context of everyday occupational therapy practice. Consequently, therapists require a range of practice resources and tools which allow them to operationalise expectations for best practice. This paper discusses the development and investigation of one such tool, the Model of Human Occupation Screening Tool (MOHOST version 1.0) (Parkinson, et al, 2002). The MOHOST is designed to be an occupation focused, evidence based, client centred, theory driven assessment that can be readily integrated into and be useful for practice. The purpose of this study was to empirically test the MOHOST (version 1.0) inclusive of clinical utility.
Development of the MOHOST
The MOHOST is based on the Model of Human Occupation (MOHO) (Kielhofner, 2002). MOHO is concerned with embracing the complexity of a client's occupation (Creek, 2003). Moreover, MOHO is an occupation focused (Pedretti, 1996), evidence based (Lae et al., 1997) theoretical framework that has associated assessments and interventions (Hagadorn, 1997). Practitioners report that MOHO provides both a theoretical understanding of occupation and the tools for doing occupationally focused practice (Forsyth, 2001), thereby providing a framework for "thinking" in practice. MOHO has been built on a scholarship of practice philosophy that encourages partnerships between academia and practice in order to deliver and generate evidence based practice (Forsyth, 2004; Forsyth, Duncan & Summerfield Mann, 2005a, Forsyth, Melton & Summerfield Mann, 2005b; Harrison & Forsyth, 2005; Taylor, Braveman & Forsyth, 2002). The scholarship of practice partnership which developed the MOHOST was initially between the second author and the University of Illinois at Chicago (led by the first and third authors). It was later expanded to include UK therapists within Central North West London Mental Health NHS Trust; Gloucestershire NHS Partnership NHS Trust; The State Hospital, Carstairs; NHS Lanarkshire; NHS Lothian; and Coventry Teaching Primary Care Trust. These partnerships ensured that the MOHOST was developed with relevance to mental health, forensic mental health, learning disability, and physical disability services within the United Kingdom. International consultation was also sought and this has resulted in many translated versions including Arabic, Chinese, Danish, Dutch, Finnish, French, German, Hebrew, Icelandic, Italian, Japanese, Korean, Lithuanian, Malaysian, Norwegian, Persian, Portuguese, Slovenian, Spanish, and Swedish.
The MOHOST was revised in the light of this clinical and academic feedback and also scrutinised in light of cultural variations. The MOHOST was, therefore, built within a community of national and international academics and practitioners who were working together as "practice scholars" (Harrison & Forsyth, 2005).
Description of the MOHOST (version 1.0)
The MOHOST aims to give a broad overview of occupational participation. It consists of 24 items, four for each of the following 5 sections: Volition (or 'motivation for occupation'), Habituation (or 'pattern of occupation'), Communication and Interaction skills, Process skills, Motor skills, and Environment (see Figure 1). These items are all rated using the same 4-point rating scale (see Figure 2). Each rating has specific descriptors that guide the selection of an appropriate rating (see Figure 3). Thus the rating process generates a profile of strengths and weaknesses affecting the client's occupational participation, in addition to generating a measure of the client's occupational participation.
The MOHOST is a flexible assessment; it provides a comprehensive evaluation of the person using a mixed data collection method. The data gathering method is "getting to know your clients" (Parkinson et al., 2002, p.11) through observation, informal conversation, proxy report, team feedback, or medical records. The MOHOST therefore, enables occupational therapists to formalise the knowledge that they build about their clients informally over a period of time by systematically documenting their observations/interactions regarding how clients respond to occupation within a given environment.
Figure 1: MOHOST items Motivation for occupation Appraisal of abilities Expectation of success Interest Commitment Pattern of occupation Routine Adaptability Responsibility Roles Communication and interaction skills Non-verbal Skills Conversation Vocal expression Relationships Process skills Knowledge Planning Organization Problem solving Motor skills Posture and mobility Co-ordination Strength and effort Energy Environment Physical space Physical resources Social groups Occupational demands
The purpose of this study was to empirically test the MOHOST (version 1.0). The following questions were addressed in this study:
1. Do the MOHOST items define a single construct of occupational participation, thereby supporting internal validity?
2. Does the hierarchical ordering of the MOHOST items along the linear continuum of occupational participation follow an expected pattern, thereby supporting construct validity?
3. When clients are rated with the MOHOST in this study, do they show valid response patterns?
4. Is there a match between item difficulty and people's ability?
5. Does the MOHOST reliably separate clients along the continuum, from less to more occupational participation?
6. Will raters demonstrate inter-rater reliability?
7. What is the clinical utility of the MOHOST?
Ethical approval was obtained from the University of Illinois at Chicago and from South East Scotland Research Ethics Service. Nine occupational therapists were invited to participate in the study as they were using the MOHOST routinely in their practice. Five occupational therapists were from the UK and the remaining four from the USA. The occupational therapists involved in this study came from a range of practice settings including community physical disability (HIV & AIDS), adult mental health (forensic care) and learning disability (see Table 1). Each participating therapist rated one common videotaped client using MOHOST. This videotape linked therapists. Linking refers to the idea that each rater must be connected to all the other raters by virtue of a common subject or subjects, which allows comparison of the raters' degree of severity or leniency in rating. This can only be accomplished when the total pool of raters is linked together by virtue of a common subject.
Alongside this, each therapist completed an additional MOHOST with clients from their caseload. This resulted in 171 completed MOHOSTs (including 9 ratings of 1 videotaped linking subject plus 162 additional subjects). The subject size for the study, therefore, was 163 clients. Anecdotal data was systematically sought from the therapists using the MOHOST with regards to its clinical utility.
Figure 3: MOHOST rating scale for appraisal of ability Key concepts: Understanding of --Strengths & limitations --Self-awareness and realism --Belief in skill --Confidence in actual abilities N.B. Confidence in social situations is assessed in RELATIONSHIPS --Ability to take credit or criticism is assessed in RESPONSIBILITY --Ability to think rationally is assessed in PROBLEM-SOLVING 4 = STRENGTH--Supports occupational participation Realistic, recognises strengths, aware of limitations, utilises assets and shows pride * accepts risk and attempts to correct mistakes independently * acknowledges limitations but emphasises assets, shows pride in achievements * appropriately confident given skills and abilities * confident about overcoming or compensating for problems 3 = DIFFICULTY--Minor interference with or risk to occupational participation Reasonable tendency to over/under estimate own abilities, recognises some limitations * appropriately confident about abilities in most situations but may be slightly apprehensive of new situations * may be self-critical at times but generally understands their own abilities and limitations * may be slightly over-confident, not always able to anticipate problems, but able to acknowledge them as they arise * may have confidence in specific skills but doubts overall ability and needs encouragement 2 = WEAKNESS--Major interference with occupational participation Difficulty understanding strengths and limitations without support * may indicate general satisfaction but appears vague about particular strengths and limitations * moderately low perception of own abilities, self-critical about ability to engage in occupation * over confident, may overestimate abilities when engaging in occupations *requires support within occupational situations to optimally use strengths 1 = PROBLEM--Prevents occupational participation Does not reflect on skills, fails to realistically estimate or lacks pride in own abilities * can only focus on failures re. engaging in occupations and/ or sustaining a meaningful occupational life, despite strong feedback * does not express feelings about abilities (either verbally or non-verbally) * does not recognise limitations or failures, lacks realism about ability to engage in occupation * negative, expresses hopelessness/helplessness about own abilities despite feedback * puts self at risk due to over-confidence in own abilities
The data was analysed using the Rasch measurement model (Wright & Stone, 1979). Rasch analysis first converts the ordinal data generated by rating scales into interval measures (Merbitz, Morris & Grip, 1989; Wright & Linacre, 1989). Then the analysis tests the internal validity of a scale by determining whether the items of each scale coalesce to form a single dominant construct or underlying dimension; this property is referred to as unidimensionality (Haley, McHorney, & Ware, 1994; Hashway, 1978; Wright & Stone, 1979). Rasch analysis also determines whether each client was validly measured, and whether each therapist rater used each scale in a valid manner. When items, clients, and therapists are shown to meet the criteria for validity, they are said to "fit".
The mean square fit statistic (MnSq) is used to assess the fit of items, clients, and therapists (Haley, McHorney, & Ware, 1994; Hashway, 1978; Wright & Stone, 1979). The ideal value for the MnSq is 1.0. Following Wright's (1994) recommendation, mean square values above 1.4 were taken to indicate a misfit. That is to say, an item was not a valid indicator of a construct, that a client was not validly measured, or that a therapist was not using the scale in a valid manner. Mean square values below 0.8 indicate an over fitting item, for instance, an item that overlaps in content with another item and does not provide unique information.
Rasch analysis also yields item calibrations that indicate how much of the underlying construct an item represents. The order in which items of a scale are calibrated is also important for assessing the validity of a scale. Items with higher calibrations should be those which are expected to represent more of the construct (occupational participation) measured. Similarly, items calibrated lower should be those expected to represent less of the characteristic.
Client calibrations estimate the position of each person assessed on the same continuum from less to more of the construct being measured. Here, a client's calibration is the measure of the person's level of occupational participation. Clients with higher calibrations are those persons with more of the construct being measured and vice versa.
Since items and clients are calibrated on the same continuum, one can determine whether items are appropriately targeted to the levels of the trait represented by the clients. An instrument should have items whose mean is near the mean of the clients' abilities. Furthermore, the items should spread out so that they cover the range of variation represented by the clients. A scale without higher level items to measure higher level clients and lower level items to measure lower level clients can have ceiling and/or floor effects. In other words, everyone above or below a certain level will get the same score despite differences between them in the construct being measured.
Rasch analysis also gives a separation statistic that represents the number of levels into which clients and therapists are classified by their calibrations. When clients are well separated, the scale can be said to effectively discriminate between different levels of the trait being measured. This separation statistic represents the sensitivity of the scale to detect differences across clients.
Therapist fit statistics allow the consistency of individual therapist ratings to be examined when assigning skill item scores. A therapist will misfit when, compared with all other therapists, he/she demonstrates a different rating pattern. Inter- and intra-rater reliability can be established by examining the rater's mean square fit statistics.
Clients in this study were 83.44% male and 16.56% female. Forty eight percent were from the UK and 52% from the USA. Subjects were mostly of Caucasian origin however, 27.16% were of African descent and 1.2% were Asian. The subjects had a range of disabilities. Clients with learning disabilities represented 9.82% of the sample, 33.74% of clients had a physical disability, and 56.44% had a mental health challenge. The age range of the subjects was from 18-65 years, with the mean age of 40.10 years.
Table 2 provides item fit statistics, calibrations and standard errors for the items of the MOHOST (version 1.0). The MnSq statistics indicate that only two items misfit: 'physical space' (Infit MnSq 1.6; ZStd 5), and 'physical resources' (Infit MnSq 1.5; ZStd 4). The MOHOST items, therefore, work well together to define a single construct of occupational participation. The items 'roles', 'responsibility', 'occupational demands' and 'appraisal of abilities' represent higher levels of occupational participation. Items requiring lower occupational participation were motor, communication/interaction, and process skills.
The summary fit statistics for the client ability facet (see Table 3) show the mean fit to be 1.0 with an STD value of -.2. This indicates that clients rated by therapists using the MOHOST (version 1.0) fit the measurement model; that is, the people rated in this study had valid response patterns and were adequately measured by the MOHOST (version 1.0). There were clients with both physical and mental health challenges in the sample and therefore the MOHOST (version 1.0) can be used in a wide range of practice settings. Figure 5 shows the map of clients' occupational participation measures. This illustrates how the clients are measured by the occupational participation ruler created by the MOHOST (version 1.0). There is an even distribution and matching of clients along the full length of the ruler and no ceiling or floor effects are evident. This illustrates that item difficulty and client's ability are well matched. Client separation was 3.63 (see Table 3). This indicates that clients were reliably separated by the MOHOST (version 1.0) into five levels of occupational participation (Strata = [4x3.63+1]/3=5.17).
[FIGURE 5 OMITTED]
Therapists were analysed to examine whether they used the MOHOST (version 1.0) scale in a valid manner (see Table 4). None of the therapists misfit the measurement model.
Therapists reported appreciating the flexibility of the data gathering method of the MOHOST (version 1.0). This was consistent feedback from practice areas that provided services to clients who were non verbal, non cooperative or who had limited cognitive capacity. The flexibility of the assessment allowed for easier integration of the MOHOST (version 1.0) into everyday clinical practice. On average the MOHOST (version 1.0) initially took longer to complete than traditional custom and practice assessments. However, once familiar with the assessment, the time taken was similar. Many therapists described the MOHOST as a helpful tool for thinking and related this to activity analysis structures. Therapists highlighted the positive reaction to the MOHOST (version 1.0) by the multidisciplinary team. The most frequent feedback, however, was the support the assessment gave to restructuring their clinical reasoning in an occupation focused way and this helped them to project the unique contribution of occupational therapy to their teams, namely, the therapeutic use of occupation.
The current study provides evidence in support of the conclusion that the MOHOST (version 1.0) scale can function as a valid and reliable measure of occupational participation for the diagnostic groups within this study. Importantly, the items worked well together as a measure of occupational participation, clients were effectively discriminated into different levels of occupational participation, and therapists were able to use the MOHOST in a valid manner. This study represents a first step in the psychometric evaluation of the MOHOST, and further research will be needed to provide additional evidence of the assessment's reliability and validity.
The order of item calibration from more to less occupational participation was as expected, with the items 'roles', 'responsibility', 'occupational demands' and 'appraisal of abilities' representing higher levels of occupational participation. These items required that clients have higher levels of occupational participation in order to receive a higher rating. This hierarchy makes sense since fulfilling role expectations, taking on responsibility, and appraising abilities and limitations are more challenging and require the synthesis of motor, communication/interaction, and process skills (Becker & Williamson, 2005; Duvdevany, 2002; Klerk & Ampousah, 2003; Thoren-Jonsson, 2001).
Since the development of the MOHOST reflected an effort to address many of the issues faced in contemporary practice, the therapists who participated in this study were asked to provide anecdotal feedback on their experiences with the MOHOST. The following discussion focuses on the extent to which the MOHOST addressed contemporary practice demands.
Although the use of standardised assessments has been supported by the field (DeClive-Lowe, 1996; Eakin, 1989; Fricke, 1993; Stewart, 1999), one of the challenges has been finding an occupation-focused assessment that can be used with clients of limited cognitive capacity and/or the limited ability to participate in standardised assessment administration procedures (Tartar, 2004). Previous standardised assessments have not allowed flexibility in the assessment process (Fawcett, 2002; Keble, 1996). The MOHOST, however, has a mixed data gathering method (Parkinson, Forsyth & Kielhofner, 2002) that takes advantage of the process a therapist undertakes when "getting to know the client" including observation, proxy report, multi disciplinary team feedback, and review of medical records. This supports professionals' calls to ensure data is collected from a range of sources (Hagadorn, 2000; Hemphill, 1982; Shaw, 1982). Therapists felt that this flexibility allowed them to more accurately measure the occupational participation of clients with limited ability. This is important because clients who are least able to self-describe and self-advocate require careful assessment of their occupational needs. Therapists in this study reported that the MOHOST could be used with clients who did not have the ability to verbally self report or participate in formalised assessment procedures.
Time has often been described as a challenge to the use of standardised assessments (Fawcett, 2002; Fricke, 1993; Hammond, 1996). The therapists in this study did indeed find that using the MOHOST initially required more time, as with any new initiative. The flexibility of the data gathering method supported the use of the MOHOST in everyday clinical practice without too many habit changes required by the therapist. The MOHOST specifically identifies further areas for assessment, which is important when developing efficient service provision (Creek, 2002; Hemphill, 1982).
Therapists stated that the MOHOST provided them with a "tool for thinking" and for reflecting on a client's occupational life. Some described the MOHOST as an "activity analysis" i.e., a way of analysing occupations of self care, productivity, and leisure. They found that using the tool allowed them to advocate their unique contribution to the health of clients, i.e. the use of occupation as a therapeutic agent. When all members of an OT department used the MOHOST it provided a cohesive way of defining their role to the team and their clients. Activity analysis has been identified as one of the keys to treatment in occupational therapy (Hagedorn, 2000; Lamport, Coffey & Hersch, 1996; Trombly, 2002). Recently there has been some discussion which advocates using theories as a framework for activity analysis (Crepeau, 2003; Toglia, 2003). The MOHOST provides a theoretical framework for analysing activities since it reflects a practice based theory. Practice based theories have the added advantage of providing an understanding of how different elements of analysis relate to each other and they provide an insight into the change process (Creek, 2003). MOHO has an established evidence base to support how different theoretical constructs relate to each other (Barris, Dickie & Baron, 1988; Ebb, Coster & Duncombe, 1989; Hallet, Zasler, Maurer & Cash, 1994; Lederer, Kielhofner & Watts, 1985; Peterson et al., 1999) and has a theory of how therapeutically supported change happens (Kielhofner, 2002). It could, therefore, be argued that using the MOHOST to analyse occupations has several advantages over traditional activity analysis frameworks, as it simultaneously provides:
a) An analysis of the person's occupational life,
b) How the different aspects of this analysis relate to each other, and
c) How this analysis relates to the changes that potentially can be made to support the client to re-engage in everyday life.
This view has been supported by the inclusion of motor and process skills (Fisher & Kielhofner, 1995; Kielhofner, 2002) along with communication and interactions skills (Forsyth, Salamy, Simon & Kielhofner, 1998) in the occupational therapy practice framework (AOTA, 2002).
The MOHOST provided the therapists with a strong occupation focused framework which fed into promoting their unique contribution to health: that of engagement in occupation. The language within the MOHOST was specifically designed to promote clarity within multi disciplinary communications. This is critical to ensure there is a coordinated approach of perspective within teams (Ovretveit, Mathias & Thompson, 1997). Therapists reported that multidisciplinary teams warmed to the assessment, finding it helpful when making decisions about discharge from acute care, attendance at day hospital, progress in chronic enduring populations, and when determining the levels of support that were needed. In a practical way the MOHOST provided the answer to Fisher's (1998) question about our occupation focus, namely, "How can we make the philosophical foundations of our profession a reality of everyday practice?" (p.513). Occupation focused, theory driven assessments provide a structure for delivering occupation focused practice. Occupation is complex (Creek, 2002) and therapists need efficient ways of embracing this complexity within the realities of everyday practice. The therapists described the MOHOST as being helpful for "occupation focused thinking". There is much emphasis being placed on the importance of reflective practice as a means of ensuring practitioners are competent to practice (Astor, Jefferson & Humphrys, 1998), as such reflective practice is fundamental to the field (Johns, 2004). Any tools, therefore, that can support reflection and occupation focused thinking should be welcomed.
The current study provides evidence in support of the conclusion that the MOHOST (version 1.0) scale can function as a valid and reliable measure of occupational participation. Importantly, the items worked well together as a measure of occupational participation, clients were effectively discriminated into different levels of occupational participation, and therapists were able to use the MOHOST in a valid manner.
The current study provides evidence in support of the conclusion that the MOHOST (version 1.0) scale can function as a valid and reliable measure of occupational participation.
The clinical utility of the MOHOST is confirmed due to the flexibility of MOHOST, the speed of completion and the support it provides to structure clinical reasoning.
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Forsyth, K., Parkinson, S., Kielhofner, G., Kramer, J., Summerfield Mann, L., & Duncan, E. (2011). The measurement properties of the Model of Human Occupation Screening Tool and implications for practice. New Zealand Journal of Occupational Therapy, 58(2), 5-13.
K. Forsyth, S. Parkinson, G. Kielhofner, J. Kramer, L. Summerfield Mann, and E. Duncan.
Kirsty Forsyth, PhD, OTR, FCOT
Queen Margaret University,
Edinburgh, EH21 6UU
Sue Parkinson BA, DipCOT,
Derbyshire Healthcare NHS Foundation Trust
Gary Kielhofner, Dr PH, OTR/L
Formerly Professor and Head Wade-Meyer Chair
University of Illinois at Chicago
Jessica Kramer, PhD, MS, OTR/L
Boston University, Boston, MA
Lynn Summerfield Mann, PhD, MSc, DipCOT
London South Bank University
Edward Duncan, PhD, BSc(Hons), DipCBT
Senior Clinical Research Fellow (NMAHP RU, University of
Honorary Advanced Clinical Practitioner (NHS Forth Valley)
Table 1 Demographic data Description of subjects % Gender Female 16.56% Male 83.44% Ethnicity/race Caucasian 71.64% African descent 27.16% Asian 1.2% Country UK 48% USA 52% Diagnosis Physical disability--acute 33.74% Mental health 56.44% Learning disability 9.82% Age Range 18-65 yrs Mean 40.10 yrs Standard Deviation 9.8 yrs Table 2 Item fit statistics, calibrations and standard errors Items Measure S.E. More Roles -1.33 .13 occupational Responsibility -1.27 .13 participation Occupational demands -1.22 .13 Appraisal of abilities -1.02 .13 Less Commitment -.82 .13 occupational Adaptability -.80 .13 participation Expectation of success -.74 .12 Social groups -.58 .12 Routine -.58 .12 Problem solving -.46 .12 Physical space -.29 .12 Relationships -.10 .12 Interests -.07 .12 Planning .03 .12 Physical resources .14 .12 Knowledge .39 .12 Energy .42 .12 Organization .42 .12 Conversation .54 .12 Non-verbal skills .55 .12 Vocal expression 1.06 .12 Posture & mobility 1.71 .13 Coordination 1.96 .14 Strength & effort 2.05 .14 Infit Items MnSq ZStd More Roles .6 -4 occupational Responsibility .9 0 participation Occupational demands 1.0 0 Appraisal of abilities .7 -2 Less Commitment 1.0 0 occupational Adaptability .7 -2 participation Expectation of success .8 -1 Social groups .8 -1 Routine .8 -1 Problem solving .8 -2 Physical space 1.6 * 5 Relationships .8 -1 Interests 1.2 1 Planning .7 -3 Physical resources 1.5 * 4 Knowledge .8 -1 Energy 1.3 2 Organization .9 -1 Conversation .9 0 Non-verbal skills 1.1 1 Vocal expression 1.2 2 Posture & mobility 1.3 2 Coordination 1.3 2 Strength & effort 1.1 0 * indicates item that did not meet fit criteria Table 3: Subjects' measurement report Infit STD Mean 1.0 -.2 SD 0.4 1.4 Separation 3.63 Reliability 0.93 Table 4: Raters measurement report Infit Rater MnSq ZStd 1 .8 -4 2 1.0 0 3 1.3 3 4 1.1 2 5 .8 -3 6 1.2 2 7 .9 -1 8 1.0 0 9 1.3 2 Figure 2: MOHOST 4 point rating scale S Strength Supports occupational participation D Difficulty Minor interference with or risk to occupational participation W Weakness Major interference with occupational participation P Problem Prevents occupational participation Figure 4: Summary of MOHOST ratings Motivation for Occupation Appraisal of Expectation abilities of success Interest Commitment 4 4 4 4 3 3 3 3 2 2 2 2 1 1 1 1 Pattern of Occupation Routine Adaptability Responsibility Roles 4 4 4 4 3 3 3 3 2 2 2 2 1 1 1 1 Communication & Interaction skills Non-verbal Vocal skills Conversation expression Relationships 4 4 4 4 3 3 3 3 2 2 2 2 1 1 1 1 Process skills Knowledge Planning Organisation Problem-solving 4 4 4 4 3 3 3 3 2 2 2 2 1 1 1 1 Motor skills Posture & Strength & Mobility Co-ordination Effort Energy 4 4 4 4 3 3 3 3 2 2 2 2 1 1 1 1 Environment Physical Occupational Physical space resources Social groups demands 4 4 4 4 3 3 3 3 2 2 2 2 1 1 1 1
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|Title Annotation:||RESEARCH ARTICLE|
|Author:||Forsyth, K.; Parkinson, S.; Kielhofner, G.; Kramer, J.; Mann, L. Summerfield; Duncan, E.|
|Publication:||New Zealand Journal of Occupational Therapy|
|Date:||Sep 1, 2011|
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