KAROLINSKA INSTITUTET Institution NEUROTEC Division of Occupational Therapy Master thesis in Occupational Therapy, 20 credits D-level Spring 2008

Cross cultural validation of The Perceived Efficacy and Goal Setting System - PEGS

Author: Kristina Vroland Nordstrand Supervisor: Lena Krumlinde Sundholm

Client-centred practice is strongly supported philosophically by the profession of occupational

therapy. Client-centred practice is the ability to listen to clients, understand their priorities and

work with them in the achievement of goals that address those prioritize. The Perceived

Efficacy and Goal Setting System (PEGS) is a self-report tool for children five to nine years

of age, used to determine their perception of their own competence in everyday occupations

and to allow them to set and prioritize their goals for intervention.

The aim of this study was to make an initial evaluation of cross-cultural validity of PEGS for

Swedish conditions.

The study was performed in two steps; the first step was the translation process and the

second the content validation of PEGS. 20 children between the age of 5-14 years with a

variety of disabilities, their parents and seven occupational therapists participated in the study.

The result indicates that PEGS is valid cross-culturally and on content in Sweden for children

from seven years of age. For the age group of five to six years olds a development of the

PEGS and a cultural adaptation is necessary for school related items to be able to adapt the

PEGS for Swedish culture and society.

Key words: Cross-cultural validity, PEGS, children, self-report, goal-setting

INTRODUCTION.................................................................................................................... 1

AIM............................................................................................................................................ 4

DESIGN..................................................................................................................................... 4

METHODS ............................................................................................................................... 4 PARTICIPANTS ......................................................................................................................... 5 PROCEDURE............................................................................................................................. 7 DATA ANALYSIS ...................................................................................................................... 8

ETHICAL ASPECTS .............................................................................................................. 8

RESULTS.................................................................................................................................. 9 TRANSLATION ......................................................................................................................... 9 SELF-EFFICACY ..................................................................................................................... 10 GOAL-SETTING ...................................................................................................................... 13 CLINICAL UTILITY................................................................................................................. 14

DISCUSSION ......................................................................................................................... 15 METHODS DISCUSSION .......................................................................................................... 15 RESULTS DISCUSSION ............................................................................................................ 18

CONCLUSION....................................................................................................................... 21

REFRENCES.......................................................................................................................... 22

APPENDIX 1 .......................................................................................................................... 24

Introduction

Client-centred practice is strongly supported philosophically by the profession of occupational

therapy (Law, 1998; Law, Baptiste, & Mills, 1995; Maitra & Erway, 2006; Wressle,

Marcusson, & Henriksson, 2002). Client-centred practice is the ability to listen to clients,

understand their priorities and work with them in the achievement of goals that address those

prioritize (Canadian Association of Occupational Therapy, 1997). Clients can participate by

actively involving themselves in discussions, specifically related to occupations that they

identify to be meaningful and purposeful, by participating in goal-setting and treatment

planning and by demonstrating a desire and motivation to engage in their occupational

therapy treatment session (Law, 1998; Maitra & Erway, 2006). Success of client-centred

practice depends on two principal components. The first is the desire and ability of the client

to take part in the decision making process and the second is the desire and ability of the

occupational therapists to include clients in the decision making process. Two of the positive

outcomes of client-centred practice are increased client satisfaction and improved functional

outcomes (Law, 1998; Maitra & Erway, 2006).

Children in need of paediatric occupational therapy services often don’t have the ability to

engage in the occupations they need and want to do. Even though rehabilitation services are

family-centred it is often the parents who are setting the goals, around the occupations they

want their child to be able to perform, not the child itself.

In the UN convention of the rights of the child it’s declared that every child has the right to

express their meaning and that it should be accounted for in matters around the child

according to maturity (United Nations, 1989). To have a more client-centred approach

towards the children during occupational therapy interventions could be away to better respect

the human rights of children and to follow the convention of the rights of the child. Another

benefit could be that with a more direct client-centred approach towards the child the

interventions will have a greater meaning to the child and the process of acquiring new skills

becomes more motivating and it is easier to engage the child in the task. Establishing explicit,

challenging goals enhances motivation and improves outcomes; in contrast, simply adopting a

goal set by someone else has no lasting motivational impact (Missiuna, Pollock, Law, Walter,

& Cavey, 2006; Poulsen, Rodger, & Ziviani, 2006; Young, Yoshida, Williams, Bombardier,

1

& Wright, 1995). There is also evidence that children have their own perspective and a

personal view about their competence that differs from those of their parents but the view of

the children are valid and stable over time (Poulsen et al., 2006; Sturgess, Rodger, & Ozanne,

2002). It would therefore be of benefit for the child and the occupational therapy intervention

if the goals of the children would be taken into consideration during the goal setting process.

An issue is the difficulties in performing interviews with children around everyday

occupations at young age and make them set goals for therapy. Goal-setting is an abstract

process which is difficult for young children to understand.

The literature describes few instruments that can be used to involve the child in the goal

setting around everyday occupations; one of them is The Perceived Efficacy and Goal Setting

System-PEGS. PEGS is a self-report tool developed in Canada for children between 5 and 9

years of age. PEGS is used to determine the children’s perception of their own competence in

everyday occupations and to allow them to set and prioritize their goals for intervention

(Missiuna & Pollock, 2000; Missiuna et al., 2006) .

The Perceived Efficacy and Goal Setting System - PEGS consist of three parts. An interview

set with picture cards for the children, a caregiver questionnaire and a teacher’s questionnaire.

It is composed of 24 items that are presented sequentially as sets of two picture cards with

drawn pictures of a gender neutral child performing daily occupations. One of the pictures is

showing a child performing a daily occupation competently and the other showing a child

who demonstrates less competence. A forced choice format is used in which a statement

under each picture is read to the child. The therapist then asks the child to select the picture

which is most like him or her. The child is asked whether the picture is a lot or a little like him

or her. The cards are placed into four piles reflecting the child’s stated competence on a four

point scale from one to four. Where one is equal with a lot like the less competent child and

four is equal with a lot like the more competent child. A slightly modified version of PEGS is

used for children who have mobility limitations. Three picture cards showing children who

are using mobility aids are substituted for three picture cards in the original set. When all 24

items are administrated, the child is asked if there is any additional daily occupation that has

not been mentioned that the child would like to improve. The additional tasks are printed on a

sticky note and placed on the less competent pile. The goal-setting process begin with

selecting all the picture cards on which the child had indicated that she or he was a lot like the

child who was less competent. These picture cards are placed out in front of the child and

2

questions are asked about the depicted tasks. What makes the task difficult and how

frequently the child performs the task? Then the child is asked to indicate which task she or he

would most like to work on or get better at in therapy. The child has complete freedom to

indicate that although the task may not be performed that well, she or he may not wish to

work at it or improve performance on it during therapy (Dunford, Missiuna, Street, & Sibert,

2005; Missiuna & Pollock, 2000; Missiuna, Pollock, & Law, 2004; Missiuna et al., 2006;

Wallen & Ziviani, 2005). The parents’ and the teachers answer a questionnaire were they rate

the child’s competence on the same 24 items by marking their selection, using the same 4

point scale as the child. Concerning the teacher’s questionnaire four items are redrawn

otherwise the teachers’ questionnaire uses the same wording for the statements around the

items as the caregiver questionnaire. A forced format is used for the written statements on the

questionnaires to enhance comparability with the child scale. (Dunford et al., 2005; Missiuna

& Pollock, 2000; Missiuna et al., 2004; Missiuna et al., 2006; Wallen & Ziviani, 2005).

PEGS is a further development of the assessment tool All About Me (Missiuna, 1998). All

About Me has been tested for evidence of reliability and validity and has produced acceptable

results (Missiuna, 1998; Missiuna et al., 2004; Sturgess et al., 2002). PEGS has been used in

different studies all of them showing that children between five and ten years of age were able

to report their perception of competence in performing everyday tasks, the children were able

to identify occupational performance issues that were priorities for intervention and to

identify goals for therapy (Dunford et al., 2005; Missiuna & Pollock, 2000; Missiuna et al.,

2006) The children also expressed additional concerns about their ability to perform

occupations, which were rarely recognised by the adults (Dunford et al., 2005). The goals of

the children remained stable two weeks later. The parents and teachers rated the children’s

abilities lower then the children did and the children prioritize different goals for therapy then

their parents and teachers did (Missiuna et al., 2006).

PEGS is an instrument that could be used to encounter the child’s perspective in the goal-

setting process. Because of this it would be valuable to translate an assessment like PEGS to

use with children before interventions to involve them in the goal-setting process and through

that get a more client-centred practice for paediatric occupational therapy practice in Sweden.

A simple translation is unlikely to be successful because of language and cultural differences

(Guillemin, Bombardier, & Beaton, 1993). Both Canada and Sweden are countries with a

3

western lifestyle the two countries also have a similarities like the climate, social values,

community structure and constructions. Most of the people in the two countries use for

example a fork and knife at mealtimes and our alphabet are the same. The similarities of the

two cultures could make the cross-cultural adaptation of PEGS for Swedish conditions easier.

However Guillemin et al (Guillemin et al., 1993) has proposed guidelines for cross-cultural

adaptation. To be able to ensure cross-cultural adaptation the following steps are of

importance; forward translation by several translators, who work parallel; backward

translation by an independent professional translator; comparing the different versions and

reaching consensus about a final version; and finally pilot-testing of the final version. This

study is based on these steps for cross-cultural adaptation. Things that needed to be

considered were if the items, the wording and the pictures of PEGS were culturally bond or

applicable for Swedish conditions. Was it possible for children and parents to evaluate

strengths and weaknesses between items? What kind of goals was set and was there a

relationship between the goals of the children and their parents. Finally was it possible from

the occupational therapy perspective to use PEGS for goal setting and intervention planning in

paediatric occupational therapy settings in Sweden.

Aim

The aim of this study was to make an initial evaluation of cross-cultural validity of PEGS for

Swedish conditions.

Design The design of the study is quantitative. It’s a non experimental, cross-sectional and structured

pilot study as described in Polit & Beck (2004).

Methods

The study was performed in two steps; the first step was the translation process and the

second the content validation of PEGS for Swedish paediatric occupational therapy settings.

The administration manual in PEGS provides the occupational therapist with general

information about the content of PEGS, general administration procedures, card placement

and how to complete the summary score. Appendix A in PEGS gives besides general

information about the administration procedures also in depth information about each

depicted task and propose elaboration questions and follow up probes that can be used for a

4

more precise answer from the children. Appendix A gives all the information that is needed to

be able to complete PEGS successfully with the children, parents and teachers. Therefore it

was decided that to be able to perform the interviews in Swedish Appendix A was the most

important to translate. The interview set with picture cards for the children, the caregiver

questionnaire and Appendix A-alternative wording suggestions for PEGS cards were forward

translated independently by the first author and the co-author, after approval from the original

authors. There after a consensus discussion between the authors was done to achieve one

Swedish version of PEGS. During the translation process there were an on going consensus

discussion with the original author to attain equivalence to the content of the original version

of PEGS. A back-translation by an authorized translator was done. The back translation was

forwarded to the original author for approval. (Behling & Law, ; Guillemin et al., 1993).

A pilot-test of the Swedish version of PEGS was done in an occupational therapy setting

within the children’s local paediatric rehabilitation centre. This was done in order to evaluate

the cross cultural validation and applicability of the PEGS through testing the translated

Swedish version with in the environment where it is supposed to be used (Guillemin et al.,

1993). The PEGS interview set for the children and the PEGS caregiver questionnaire were

used to collect the data.

To evaluate the usefulness of PEGS in Sweden the participating occupational therapists

answered a questionnaire developed specifically for this study by the author. The

questionnaire enhanced possible cultural differences of PEGS and the perception from the

occupational therapists regarding the use of PEGS for planning occupational therapy

interventions.

Participants

Occupational therapists providing paediatric rehabilitation services in the region Gävleborg

were invited to participate in the study. Seven out of 13 occupational therapists from three

different rehabilitation centres entered the study. All of the occupational therapists had a

minimum of three years of experience of working with paediatric rehabilitation.

The participating children where picked through convenience sampling, up on judgment by

the participating occupational therapists. The children were picked from the case loads of the

5

seven participating occupational therapists. 20 children between the age of 5-14 years (mean

age=9 SD 2, 7), fourteen boys and six girls and their parents participated in the study.

Table I: Description of the participants by gender, age, diagnosis, school form and mobility aids. Child Gender Age Diagnosis Type of school Mobility

aids 1 Boy 7 Not established Compulsory

school None

2 Boy 9 Asperger’s Syndrome Compulsory school

None

3 Girl 9 Not established Compulsory school

None

4 Boy 5 Cerebral palsy, unilateral spastic Preschool

None

5 Girl 8 Mental retardation

Special school None

6 Boy 6 Spina bifida

Preschool Wheelchair

7 Boy 5 Cerebral palsy, bilateral spastic Preschool

Wheelchair

8 Boy 9 Spinal muscle atrophy Compulsory school

Wheelchair

9 Boy 13 Artrogryphosis Compulsory school

Wheelchair

10 Boy 10 Not established Compulsory school

None

11 Boy 11 Not established Compulsory school

None

12 Boy 12 ADHD Compulsory school

None

13 Boy 12 Not established Compulsory school

None

14 Boy 11 Not established Compulsory school

None

15 Girl 6 Cerebral palsy, bilateral spastic

Preschool None

16 Girl 14 Mental retardation

Special School None

17 Girl 10 Epilepsy Compulsory school

None

18 Girl 10 Cerebral palsy, unilateral spastic Compulsory school

None

19 Boy 6 Cerebral palsy, unilateral spastic

Preschool None

20 Boy 7 Encephalitis Compulsory school

None

6

Out of the 20 children six had no established diagnosis, but where referred to occupational

therapy because they had difficulties with everyday occupations that required motor

coordination. The remaining 14 children had an established diagnosis. The children’s

diagnoses varied and are presented in Table I. All of the children were receiving or in process

to receive occupational therapy services and 12 accessed one or more additional services such

as physiotherapy, special education, psychology or speech therapy. An important prerequisite

from an ethical perspective was that the goals of the children and parents generated by the

PEGS interview were to be addressed in consequent treatment. The participating occupational

therapists invited families with children fulfilling the following inclusion criteria to participate

in the study. The inclusion criteria were:

• The child should have an ability to interpret pictures

• The child should be functioning at or above a kindergarten level concerning receptive

language

• The child should be able to make choices between two options

Procedure

Parents of children fulfilling the inclusion criterion were invited to participate in the study.

The parents where given a letter of invitation describing the purpose of the study.

Background data were collected for the variables age, gender, and diagnosis. A PEGS

interview was conducted with the children by the first author according to the PEGS manual.

But if the child didn’t wish to work on or improve his or her performance of the tasks where

he or she had indicated that he or she was “like the less competent child”. The first author

gave the child an opportunity to select goals from the cards were he or she had indicated that

he or she was “a little like the competent child”. During the interview with the child the

parents answered the PEGS caregiver questionnaire and the occupational therapist was

present but in a passive roll.

After the interview with the child, the participating occupational therapist answered a

questionnaire consisted of a combination of open-ended and closed-ended questions (Polit &

Beck, 2004). The close-ended questions were designed to elicit responses as dichotomous

questions or as a rating scale most of the questions had a follow up question were the

occupational therapists could motivate their answers (Polit & Beck, 2004). A first part

7

included questions concerning the specific child and the usefulness of the information

generated by PEGS. A second part included questions concerning the overall structure of

PEGS and asked therapists to identify possible cultural differences. The questionnaire for the

occupational therapists can be seen in Appendix 1.

Data analysis

The data from the children, the parents and the occupational therapists was reported as

descriptive statistics. As the PEGS produces scores on an ordinal level, non-parametric

statistical methods were used (Polit & Beck, 2004). To be able to compare the goals set by the

children and their parents the goals were categorized as self-care, play/leisure and

productivity domains, defining productivity as school work (Missiuna et al., 2004).

Weighted kappa and absolute agreement were calculated for all items except the items

modified for children in need of mobility aids because of a sample size of only four child-

parent pairs. Absolute agreement was calculated in percentage. Weighted kappa and absolute

agreement was calculated to be able to determine the agreement between the ratings of the

child and the parent on item level (Viera & Garrett, 2005). The Spearman’s rank order

correlation coefficient was calculated for the total perceived efficacy scores to determine the

relationship between the child’s and the parent’s ratings (Polit & Beck, 2004).The data were

analysed using the computer program SPSS® to calculate Spearman’s rank order correlation

coefficients and the computer program STATA® to calculate weighted kappa.

Ethical aspects

The study was a quality assurance project within the action field of the Child and youth

rehabilitation centre in the County Consil of Gävleborg and had approval from the managing

director. Informed consent for inclusion in the study was obtained from the parents. The

parents were informed about the intended use of the data. For the benefit of the children the

goal setting was followed by an intervention period. A summary of the goals of the child was

reported to the participating occupational therapist and an intervention plan was done. The

parents and the children had the possibility to withdraw from the study whenever they wished

8

Results

Translation

During the translation of the items in PEGS to Swedish some words were identified where a

direct translation was not possible. A corresponding word was not found or the meaning of

the word didn’t seem meaningful in the context. These words were discussed with the original

author and than translated in to Swedish. The words where a direct translation was not

possible are presented in Table II together with an explanation of the words in English.

Theses explanations were used to translate the words into Swedish.

Table II: Explained words. The origin word Explanation in English Gym Physical education class.

Intramurals Sports Sports activities that are conducted during

school - at lunch or after school - usually competitive.

Journal A booklet that children complete every day - they usually write a paragraph about their day.

Sticky-Zipper A zipper that won’t get started, it - sticks at the bottom.

Pick-up activity A sports activity that happens casually in the community.

Mechanical aspects Manipulating the pens, marking pens, pencils, rulers, scissors etc.

Setting Place, environment

Elaborate Further develop

Probe Investigate, examine

During the consensus discussion to achieve one Swedish version some cultural differences

were seen immediately. These concerned specific examples of activities, sports, sandwiches

that are mentioned in the text. These examples are culturally bond and several of them do not

exist in Swedish culture. In discussion with the original author the wording for the examples

were changed to alternatives more culturally suitable in Sweden. For example lacrosse was

9

replaced for field hockey; sandwiches with marmite were replaced for sandwiches with Kalles

Kaviar.

During the translation process the picture of each item was also discussed to find consensus in

if the tasks represented meaningful occupations for children in a Swedish culture. Two

pictures representing tasks that are performed differently in Sweden were identified. The

pictures that needed to be changed were the picture of the item Tidy desk and the picture of

the item Ball games. The set of picture cards for the item Tidy desk shows only a desk, one

that is tidy and one that’s messy. In Sweden children in compulsory school does not always

have desks where their books are stored sometimes they are provided their own drawer or a

specific part of a cupboard to store their school materials. To adjust this item for Swedish

conditions the statement under the picture of the desk was changed so that it also contained

the word drawer.

The set of picture cards for the item Ball games shows a child playing baseball. Because of

the fact that baseball is not a common sport in Sweden the text accompanying the picture

needed supplementation. To adjust this item for Swedish conditions it was explained to the

children that the child on the picture playing baseball also could be a child playing for

example tennis or field hockey. This was explained to the child before he or she rated his or

her competence for the depicted task. For the future the depicted task of a child playing

baseball should be replaced with a picture of a child performing any other common ball game

in Swedish culture that involves using a long object to connect to a moving target. The

depicted task ball games suggestively could be replaced with field hockey as this is a common

sport and leisure activity in Sweden.

The final Swedish version was back translated to English by an authorized translator and

subsequently approved by the original author.

Self-efficacy

The children were able to identify whether they thought they where good or not good at

performing the daily tasks depicted on the PEGS picture cards. They all could identify both

strengths and weaknesses in their own performance of every day occupations and all of them

could indicate whether they thought they were a lot or a little like the child on the picture. No

child identified himself or herself only with the less competent child or with the competent

10

child for all items. The parents were also able to identify the depicted tasks as well-known and

rate the children’s competence performing the daily tasks depicted in PEGS.

Children in first grade and older and their parents typically completed all the items. Children

in preschool and their parents were not able to rate the child’s competence on one or several

to four specific school related items. These items were Finishing schoolwork on time,

Organizing numbers, Printing neat and Keeping desk tidy. This difference could be explained

with cultural differences in school systems in Canada and Sweden.

Table III: Mean value, category and goal selection by item.

PEG

S It

em

Cat

egor

y

Mea

n PE

GS

scor

e ch

ildre

n

Num

ber

of ti

mes

se

lect

ed a

s a g

oal

by a

chi

ld

Mea

n PE

GS

scor

e pa

rent

s

Num

ber

of ti

mes

se

lect

ed a

s a g

oal

b y a

par

ent

Skipping** Leisure 1,5 1,5 Tying shoes Self-care 2,2 7 1,3 4 Bathroom** Self-care 2,3 1 2,0 1 Finish school work on time Productivity 2,4 5 2,2 1 Skipping* Leisure 2,5 4 1,3 Buttoning Self-care 2,8 3 2,5 Kicking* Leisure 2,8 4 2,3 Games sports Leisure 2,9 3,1 Keeping up** Self-care 3,0 1 2,8 Dressing Self-care 3,0 2,6 4 Desk Productivity 3,1 3 2,5 Running* Leisure 3,1 4 2,4 1 Ball games Leisure 3,2 1 2,2 Scissors Productivity 3,2 2 2,5 1 Catching balls Leisure 3,2 2 2,5 1 Painting Leisure 3,2 3 2,6 2 Cutting food Self-care 3,2 2 2,7 2 Making things Leisure 3,2 2 2,8 Org. numbers Productivity 3,2 2 3,0 Sports Leisure 3,3 2 2,4 1 Playground Leisure 3,3 3,1 Bicycle Leisure 3,3 3 2,2 3 Printing Productivity 3,4 2,4 3 Zipping Self-care 3,4 3 2,9 Drawing Leisure 3,5 1 2,4 1 Video games Leisure 3,5 1 3,3 Computer Productivity 3,9 3,7 1 ** Items only for children who use mobility aids * Items only for children who does not use mobility aids

11

The mean value of perceived efficacy for each of the 24 item was calculated, from the number

of children and parents respectively, who gave ratings for the items. The mean value shows

which items that were perceived as more or less difficult. The variation of the mean values

indicates that the children were discriminating between items on which they were more or less

competent, rather than responding at a consistent level of perceived competence no matter

what the daily task was. Mean values for each item is presented in Table III.

Both the mean values for each item, the weighted kappa calculations for each item and the

total perceived efficacy scores indicates that the children and their parents differ in their

perception of the child’s competence. Agreement about the child’s level of competence for

individual items were calculated using weighted kappa scores which indicates when

agreement between each of the respondent pairs is higher then would have been expected by

chance. The agreement of perceived efficacy between the child and the parent for each item is

higher as the weighted kappa value comes closer to one. Weighted kappa scores and absolute

agreement is presented in Table IV.

The total perceived efficacy scores can range from 24-96 a higher score indicating better

efficacy. In this study, the scores from the parents ranged from 30-80 and the scores of the

children ranged from 42-88. All of the children tended to report a higher level of competence

both on item level and on the total perceived efficacy scores than their parents did. Although

the children tended to rate themselves more competent then their parents rated them, there

were relationships among the group regarding the overall ratings of a child’s competence.

Spearman’s rank order correlation coefficient among groups of respondents for the total

PEGS scores was significant at a p<0, 01 level with a correlation between the scores reported

by the children and the parents (r=0,631).

12

Table IV. Weighted Kappa Calculations and Percentage of Absolute Agreement for each item. Item Weighted kappa

Child - ParentAbsolute

Agreement (%)

Catching balls 0,1739 25Cutting food 0,6351 52Sports 0,4706 25Videogames 0,3568 63Finishing schoolwork 0,2911 28Making things 0,2361 50Games/sports 0,1214 21Tying shoes 0,3667 42Scissors 0,3852 30Playground 0,0312 45Buttoning -0,0238 25Computer -0,0714 75Organizing numbers 0,5059 50Bicycle 0,0215 15Dressing 0,1004 15Ball games 0,3856 40Writing 0,3362 44Zipping 0,5848 40Tidy desk 0,6196 53Painting 0,3621 55Drawing 0,3303 35Skipping* 0,1400 37Kicking* 0,3162 19Running* 0,1884 37* Items only for children who isn’t in need of mobility aids

Goal-setting

The children were able to select goals for therapy and were usually able to indicate clearly

what tasks they wanted to work on and why. Their goals were personal and varied. The

children’s goals were different than those of their parents.

Firstly the goals of the children were more strongly connected to the items presented in PEGS

were as the goals of the parents were strongly connected to the freely identified so called

additional goals. The parents identified a number of 27 additional goals. These 27 goals

mainly concerned goals around function such as coordination, strength and mobility or

behavioural problems such as being able to solve conflicts, end an activity without getting

angry or toileting such as being able to go to the toilet in time, being independent in bottom

wiping, tooth brushing and hand hygiene and being able to tell the time. The children

identified a total of seven additional goals. The additional goals for the children were being

13

able to go to the toilet in time, eating ice-cream without getting messy, being able to hold ones

breathe under water, being able to get in and out of a sleeping bag, being able to reach things

that are placed high up, cross country skiing and making better notes. Secondly the goals of

the children had an over representation on leisure goals the children selected a total of 29

leisure goals, 16 self-care goals, 11 productivity goals and 7 additional goals. Where as the

parents selected a total of 11 leisure goals, 9 self-care goals, 6 productivity goals and 27

additional goals. Finally the children often identified different kinds of goals than their

parents but ten children out of 20 had one goal identical with there parents, two children out

of 20 had more than one goal identical with their parents, Two children, aged six years and

nine years did not want to set any goals for therapy, they expressed that all was fine the way it

was.

The goals most frequently selected by children in descending order were tying shoelaces,

finishing schoolwork on time, skipping, kicking a ball and running. The goals most frequently

selected by the parents in descending order from the PEGS items were tying shoelaces,

getting dressed, printing and bicycling. Four children used the opportunity to select goals also

from the pile of “a little like the competent child”. The mean value for the children’s and the

parents’ goal selection by item and category are shown in table III.

Clinical Utility

All of the occupational therapists in the study reported that they found PEGS suitable for

Swedish conditions. They all thought that PEGS increased the child’s possibility of

participating in the process around interventions, that PEGS easily could be implemented in

their daily practice and that the items in PEGS all were suitable for paediatric rehabilitation

settings.

Out of 20 children 13 were previously known or well-known to the occupational therapists.

For 19 out of 20 children the occupational therapists felt that they increased their knowledge

about the child’s perception of her or his own competence through PEGS. For 11 out of 20

children the occupational therapists felt that PEGS gave them new knowledge about the

child’s difficulties in performing daily occupations. Of those eleven children were six children

new to the occupational therapists. For 15 out of the 20 children the occupational therapists

felt that the items in PEGS were relevant for their diagnoses. For the remaining five the

occupational therapists expressed that the items in PEGS were relevant for the diagnosis but

14

they lacked items around personal hygiene, understanding of time and behavioural problems.

The occupational therapists thought that 17 out of 18 children who established goals for

therapy selected goals that were to a certain amount suitable or fully suitable for the child.

The occupational therapists commented that they found the assessment tool PEGS quick and

easy to administer. They indicated that the pictures helped to provide structure for the process

and that the children easily identified themselves with the pictures. Some of the occupational

therapists experienced that the children felt that the process was meaningful, motivating and

fun. They also noted that PEGS provided a positive focus on goals rather than on deficits.

According to the occupational therapists the goals of the children had a clear focus on

occupation and occupational performance which appealed to them and made the intervention

planning more easily.

Discussion

Methods discussion

To be able to achieve better equivalence with the original assessment the literature suggests

several independent forward translation as well as back translations until consensus finally is

reached (Behling & Law, 2000; Guillemin et al., 1993) . In this study two separate forward

translations were done, which can be regarded as few and a bias might have aroused. A bias

occurse if the content of the Swedish version is not equivalent to the original version of

PEGS. But as PEGS has a simple language adapted for children and involve tasks common to

Swedish culture it was decided that two independent translations would be enough to establish

equivalence with the original version of PEGS. The direct contact with the original author and

the on going consensus discussions with the original author through the translation process

enhanced the belief that the content of the Swedish translated version of PEGS was equivalent

with the content of the original version of the PEGS.

The occupational therapist was first invited to participate in this study and then the children

were picked through convenience sampling. That is, available subjects were enrolled as they

entered the study until the desired sample size was reached (Depoy & Gittlin, 1998). This

could be a limitation of the study since both the occupational therapists and the chosen

children and their parents could be a sample of people atypically positive to a development of

more client-centred occupational therapy. Since the purpose of the study was to describe not

15

to generalize the findings, the study could in another way benefit from this sampling method

in that way that the variety of diagnosis could be encountered for and thereby a rich

description could be obtained.

Studies that measure agreement between two or more observers should include a statistics that

takes into account the fact that observers will sometimes agree or disagree simply by chance.

The kappa statistics is the most commonly used statistic for this purpose. A kappa value of

one indicates perfect agreement, whereas a kappa value of zero indicates no agreement, i.e.

the level of agreement is equivalent to chance alone (Viera & Garrett, 2005). As PEGS

produce ordinal level data on a four point scale, agreement between the different scale steps

are of interest. For example, if a child rates perceived competence as a one and a parent rates

the child’s competence as a four there is no agreement. But if the child and the parent rate the

child’s competence as a three and a four respectively, the child and the parent do not have an

absolute agreement but are close in their interpretation of the child’s competence and a fair

agreement would be present. To statistically calculate this type of agreement and take into

account the size of a disagreement, weighted kappa is used (Viera & Garrett, 2005).

Therefore, to encounter this, weighted kappa calculations were done to look at the agreement

between the ratings of each individual child and his or her parent. To be able to compare the

weighted kappa value with total agreement, absolute agreement was calculated on item level.

Absolute agreement is when the child and the parent rate the child’s competence totally alike.

Absolute agreement for each item was also calculated since weighted kappa has its limits in

being sensitive to prevalence and rare findings. This is what happened for the item Computer,

were an absolute agreement of 75 % generated a weighted kappa value of only – 0,0714. In

this case the children and the parents only used a few of the four rating categories, since most

of them agreed that the child’s competence was “a lot like the competent child”. The

distribution of the samples ratings then ended up in a corner of the cross tab and generated a

negative weighted kappa value. To get a high weighted kappa value it is important that all of

the categories of a scale are represented and distributed along the diagonal in a cross tab. With

a large sample size the possibility that all the ratings are being used increases. This sensitivity

for the distribution of a samples ratings is a weakness in weighted kappa(Viera & Garrett,

2005). To interpret the item computer just by using the weighted kappa calculations would

indicate an agreement weaker then by chance between the ratings of the child and the parent,

although the absolute agreement was quite high.

16

For the three items in PEGS that are to be used with children in need of mobility aids

statistical analysis were not calculated because of a sample size of only four child-parent

pairs. In a sample size that small the calculations looking for agreement on item level between

the child and the parents will not be accurate. Therefore a decision was made not to use these

items in the weighted kappa calculations.

Spearman’s rank order correlation coefficient was used to calculate the relationship between

the children’s and parent’s overall rating (sum scores) of the child’s competence. Spearman’s

rank order correlation coefficient was chosen because it is a non-parametric method and that

ordinal level data was compared (Polit & Beck, 2004).

To collect data from the participating occupational therapists a self-report was used. The use

of self report questionnaires instead of an interview overcomes the interviewer bias that

accurse when there is an interaction between the interviewer and the respondent. This

interaction can effect the responses then a bias occurs.(Polit & Beck, 2004) In self-reports

there are instead always the possibilities that responses will be neglected or overlooked just

because this interaction between the interviewer and the respondent is absent. It is easier to

ignore a questionnaire then a interviewer (Polit & Beck, 2004). To strengthen the study a

combinations of both open-ended and closed-ended questions were used to offset the

strengths and weaknesses of the self-report questionnaire (Polit & Beck, 2004). The close-

ended questions were designed to elicit responses as dichotomous questions or as a rating

scale (Polit & Beck, 2004). The self-report questionnaires were personally presented to the

occupational therapists. The author was present to be able to explain or clarify items or study

purpose this is known to have a positive effect on response rates (Polit & Beck, 2004).

Reliability test were not performed on the self report questionnaire for the occupational

therapists. The questions were assumed to be appropriate after being analyzed by experienced

occupational therapists.

This study is a pilot study which makes the results limited in generalizability because of the

small numbers of children who participated. Further research using a greater number of

children will be required in order to generalize the findings of this study to a population.

However the study, confirmed the results of earlier studies (Dunford et al., 2005; Missiuna &

Pollock, 2000; Missiuna et al., 2006) which increases the strength of these findings.

17

Results discussion

As mentioned before both Canada and Sweden are countries with a western lifestyle and of

similar culture. The similarities of the two cultures made the cross-cultural adaptation of

PEGS for Swedish conditions easier. The Children could identify themselves with the

depicted tasks because the tasks were familiar and well-known in their own context. Even

though we are so a like it is important to note that there were differences that needed to be

considered. A few changes both in the wording the pictures and the items should be done to

make PEGS valid for Swedish conditions.

For children in the age group five to six years old the items Finishing schoolwork, Organising

numbers, Printing and Tidy desk needs to be adjusted to suit the Swedish preschool activities.

At age five Swedish children are not yet in school and pre-school does not formally teach e.g.

writing and doing math by writing numbers. For these items both the pictures and the wording

needs to be adjusted to enhance more general information around the child’s perception of his

or her ability to initiate and continue with a task, arrange work/drawing spatially on a paper

and the ability to organise the workspace. A way to develop such content of these items could

be to use focus groups and in discussions with educationalists in Swedish preschool develop

wording of tasks that culturally could replace these items.

For the item ball games the need to replace the base ball player with another sports player was

recognized but the picture wasn’t changed before the interviews were performed. The

impression from the interaction with the children was that they had ability to rethink the item

from the verbal explanation and elaboration of the interviewer. Even though it was not found

necessary to change the picture it would be preferable to increase the possibility for the

children to identify themselves with a more culturally bond task.

The results in this study, corresponds well with the findings of earlier studies in several

aspects (Dunford et al., 2005; Missiuna & Pollock, 2000; Missiuna et al., 2006). Although the

children were clearly able to identify which tasks were less successful for them, they

consistently indicated an overall belief about their competence that was higher than that

identified by their parents. Agreement among the ratings of the child and the parents around

the competence of the child was week to moderate on items level. Some might suggest,

therefore that the scale is not valid for use with children but an alternative view could be

presented that is that the views of the children are different but still valid and that both the

18

parents and the children are contributing a different perspective (Missiuna et al., 2006;

Sturgess et al., 2002). It is important to note that the focus in PEGS is not the ability to

measure the child’s competence in relation with the parents. The most important issue with

PEGS is the ability to establish challenging goals that are motivating both for the child and

the parent(Missiuna et al., 2004). Therefore the scores in PEGS are not the most important the

most important issue is the established goals. This enhances the need for assessments like

PEGS were the goals of the children could be taken into consideration during the goal setting

process. The goals for intervention can then have focus both on the needs of the children, the

needs of their parents and become more motivating for the child and in that way improve the

outcome of the intervention.

Another aspect that makes the use of PEGS important is that the goals of the children and

their parents are different. This information is important to enhance for the paediatric

rehabilitation centres where the parents often set goals for their children. A challenge can be

to establish goals and interventions that have a clear focus on leisure activities which was the

most selected form of goals established by the children, this was also confirmed by earlier

studies(Dunford et al., 2005; Missiuna & Pollock, 2000; Missiuna et al., 2006).

In administrations of PEGS therapists ask the children to prioritize goals around the items

were the child has rated herself or himself “a lot less competent” or “a little less competent”.

In this study children who had difficulties in selecting goals from these piles also got the

opportunity to select goals from the pile “a little like the competent child”. When they were

given this opportunity they succeed and found goals for intervention. We know that children

both in this study and in former studies consistently indicate an overall belief about their

competence as higher than that identified by their parents. Than maybe the opportunity to

choose from “a little like the competent child” should have been offered to all of the children

and maybe this is where the goal setting should begin to make certain that the goals will be

reachable in a fair amount of time. Children choosing from “a little like the competent child”

strengthen the belief that the children selected goals that were important and reachable for

them. In goal focused interventions it’s commonly known that goals reachable in close range

enhances motivation and improves outcomes; in contrast, simply adopting a goal set by

someone else has no lasting motivational impact (Missiuna et al., 2006; Poulsen et al., 2006;

Young et al., 1995).

19

PEGS is recommended for use with children between five and nine years of age (Missiuna et

al., 2004). An interesting new finding in this study, was that even children between nine and

fourteen years of age were able to identify strengths and weaknesses in their own performance

of the daily occupations and select goals as depicted in PEGS. They also engaged in PEGS

and found it motivating to use for goal-setting. This indicates that in paediatric rehabilitation

settings in Sweden PEGS can be used also with this age group of children and teenagers with

disabilities to provide a structure for the rating of perceived efficacy and for the goal-setting

process.

A possibility to develop the items in PEGS could be interesting. In this study both the

occupational therapists and the parents expressed concerns around activities like toileting for

children who is not in need of mobility aids, behavioural aspects as being able to walk away

from a provocation, stop an activity with out getting angry and being able to tell the time. This

is aspects that often are discussed in paediatric rehabilitation centres when interventions are

planned. To be able to also have the views of the children would maybe enhance the

motivation and make the intervention more personal for the child. If the child’s perspective is

encountered the goals could become more specific towards the child’s perspective about what

becomes a problem in those activities.

The benefits associated with the use of the PEGS in clinical settings were supported strongly

by the occupational therapists who participated in this study. They reported that the PEGS

helped in building rapport and was a positive experience for the child. They were able to hear

the child’s priorities and get the perspectives of parents as well. The children were able to

identify goals that were important to them and according to the occupational therapists also

suitable. The questionnaires from the occupational therapists gave valuable feedback

regarding missing items and cross-cultural scale adjustment concerns. This feedback from the

occupational therapists increased the quality of the validation of the Swedish version and

strengthens the need for adaptation of the PEGS especially for children in the age groups of

five to six years.

For further research, it would be of interest to develop the items Finishing schoolwork,

Organising numbers, Printing and Tidy desk for children in the age group of 5-6 years of age

so that a Swedish version that is valid on content can be used on a larger sample size were the

limitations from this study could be taken in consideration. Especially, a larger sample of

20

children using mobility aids is needed. Another aspect would be to investigate the

implementation of PEGS for goal-setting and effects of intervention focusing on these goals.

In this type of study PEGS could for example be used together with the goal attainment scale

(GAS). The GAS could be used to evaluate goal achievement for each specific child

(MacLaren & Rodger, 2003). Of interest could also be to interview the parents about their

view around child focused goal setting and treatment planning. Today it’s more common that

the parents together with therapists set the goals for their children. A perspective were the

child’s own view is taken into consideration may alter the current way of intervention since it

may affect the type of goals that will be chosen. Therefore it would be interesting to here the

views of the parents.

Conclusion

The findings of this study indicate that PEGS is valid on content in Sweden for children from

seven years of age. However for the age group of five to six years olds a development of the

PEGS and a cultural adaptation is necessary for school related items to be able to adapt the

PEGS for Swedish culture and society.

21

Refrences

Behling, O., & Law, K. S. (2000). Translating Questionnaires And Other Research

Instruments: Problems and solutions. Canadian Association of Occupational Therapy (1997). Enabling occupation: An

occupational therapy perspective. Ottawa: ON: CAOT Publications ACE. Depoy, E., & Gittlin, L. (1998). Introduction to Research: Understanding multiple strategies

(Second ed.). St. Louis: Mosby Inc. Dunford, C., Missiuna, C., Street, E., & Sibert, J. (2005). Children's Perceptions of the Impact

of Developmental Coordination Disorder on Activities of Daily Living. British Journal of Occupational Therapy, 68(5), 207-214.

Guillemin, F., Bombardier, C., & Beaton, D. (1993). Cross-cultural adaptation of health-related quality of life measures: literature review and proposed guidelines. Journal of Clinical Epidemiology, 46, 1417-1432.

Law, M. (1998). Client-centered occupational therapy: Slack Inc. Law, M., Baptiste, S., & Mills, J. (1995). Client-centred practice: What does it mean and does

it make a difference? Canadian journal of occupational therapy, 62(5), 250-257. MacLaren, C., & Rodger, S. (2003). Goal attainment scaling: Clinical implications for

paediatric occupational therapy practice. Australian Occupational Therapy Journal, 216-224.

Maitra, K. K., & Erway, F. (2006). Perception of Client-Centered Practice in Occupational Therapists and Their Clients. The American Journal of Occupational Therapy, 60(3), 298-303.

Missiuna, C. (1998). Development of All About Me, an instrument which measures children's perceived motor competence. Occupational Therapy Journal of Research, 18(2), 85-108.

Missiuna, C., & Pollock, N. (2000). Perceived efficacy and goal setting in young children. Canadian journal of occupational therapy, 67(2), 101-108.

Missiuna, C., Pollock, N., & Law, M. (2004). PEGS, The Perceived Efficacy and Goal Setting System: Harcourt Assessment, Inc.

Missiuna, C., Pollock, N., Law, M., Walter, S., & Cavey, N. (2006). Examination of the Perceived Efficacy and Goal Setting System (PEGS) With Children With Disabilities Their Parents and Teachers. The American Journal of Occupational Therapy, 60(2), 204-214.

Polit, D. F., & Beck, C. T. (2004). Nursing Research principles and methods: Lippincott Williams & Wilkins.

Poulsen, A., Rodger, S., & Ziviani, J. (2006). Understanding children's motivation from a self-determination theoretical perspective: Implications for practice. Australian Occupational Therapy Journal(53), 78-86.

Sturgess, J., Rodger, S., & Ozanne, A. (2002). A Review of the Use of Self-report Assessment with Young Children. British Journal of Occupational Therapy, 65(3), 108-116.

United Nations (1989). The UN convention on the rights of the child. Retrieved 14 May, 2008, from http://www.unicef.se/barnkonventionen

22

Wallen, M., & Ziviani, J. (2005). PEGS, The perceived efficacy and goal setting system. Australian Occupational Therapy Journal, 52, 266-267.

Viera, A., & Garrett, J. (2005). Understanding Interobserver Agreement: The Kappa Statistic. Family Medicine, 37(3), 360-363.

Wressle, E., Marcusson, J., & Henriksson, C. (2002). Clinical utility of the Canadian Occupational Performance Measure - Swedish version. Canadian Journal of Occupational Therapy, 40-48.

Young, N., Yoshida, K., Williams, I., Bombardier, C., & Wright, J. (1995). The Role of Children in Reporting Their Physical Disability. Archives of Physical Medicine and Rehabilitation, 76(October), 913-918.

23

Appendix 1

Enkät Du har just deltagit i en PEGS-intervju med ett barn. Nedanstående frågor gäller detta specifika tillfälle. 1. Hur väl känner du detta barn sedan tidigare? 1 2 3 4 5 6 7 Inte mycket alls väl 2. Barnets ålder _________ och diagnos ___________________ 3. Hur väl stämmer barnets egen bedömning av sina förmågor/svårigheter överens med din uppfattning av barnets svårigheter? 1 2 3 4 5 6 7 Inte helt alls 4. Fick du genom PEGS ny kunskap om någon/några svårigheter barnet har? Ja Nej Om ja, vilka. 5. Upplever du att PEGS gav dig ökad kunskap om barnets/barnens uppfattning av sin förmåga? Ja Nej

24

Om ja gå till fråga 6. 6. Är denna kunskap användbar för att planera behandling? Motivera ditt svar. 7. Hur relevanta anser du att frågorna/frågeområdena i PEGS är för barn med denna diagnos? 1 2 3 4 5 6 7 Inte helt alls 8. Behöver något förändras för att passa detta barns behov? 9. Hur väl stämmer de identifierade målen överens med din uppfattning av lämpliga mål för detta barn? 1 2 3 4 5 6 7 Inte helt alls 10. Finns det viktiga målområden för detta barn som inte kommer fram i PEGS intervjun? Vilka?

25

11. Vad tycker du om de mål barnet kom fram till? Är de t.ex. relevanta, kan de uppnås, kan man inom habiliteringen hjälpa barnet uppnå målet? 12. Vilken yrkeskategori tror du bäst kan hjälpa barnet uppnå målen? 13. Tror du barnets mål stämmer överens med föräldrarnas? Ja Nej Om nej gå till fråga 14. 14. På vilket sätt tror du de skiljer sig åt?

26

Enkät Du har deltagit i PEGS-intervjuer med _______ st barn. Dessa frågor gäller din uppfattning om PEGS användbarhet i allmänhet. 1. Vilka användningsområden ser du för PEGS inom habiliteringens verksamhet? 2. Vad anser du är bra med PEGS? 3. Anser du att PEGS frågeområden är relevanta för svenska förhållanden? Ja nej Om nej, gå till fråga 4. 4. Vad passar inte och/eller vad behöver läggas till?

27

5. Anser du att PEGS frågeområden är relevanta för barn inom habiliteringen? Ja nej Om nej, gå till fråga 6 6. Vad passar inte och/eller vad behöver läggas till? 7. Upplever du att PEGS styr/hjälper barnet/barnen identifiera meningsfulla mål? Ja Nej Om ja gå till fråga 8. Om nej gå till fråga 9. 8. På vilket sätt är målen meningsfulla? 9. På vilket sätt är målen inte meningsfulla?

28

10. Tror du att PEGS kan öka barnens delaktighet när det gäller insatserna från habiliteringen? Ja Nej 10 a. Vilka svårigheter ser du? 10 b. Vilka vinster ser du? 11. Tror du att PEGS kan implementeras i ditt arbete som arbetsterapeut? Ja Nej 11a. Vilka svårigheter ser du? 11b. Vilka vinster ser du?

29

12. Övrigt.

30