Barriers to Occupational Balance in Daily Living: Perspectives of University Students with Physical Disabilities

Conceptual Foundations of Occupational Balance

• Occupational Balance (OB) Definition: A core concept in occupational therapy defined as the subjective experience of having a meaningful distribution of time and engagement across self-care, productivity, and leisure activities. It involves having the "right mix" and amount of occupations that are personally significant to the individual.
• Significance of OB: It serves as a key determinant of health, well-being, resilience, and academic performance. Higher levels of OB are associated with lower levels of depression, anxiety, and stress.
• International Classification of Functioning, Disability and Health (ICF) Framework: Identifies daily occupations within four primary domains:
  • Self-care
  • Mobility
  • Productivity
  • Leisure
• Higher Education Context: For university students, maintaining balance across these domains supports social relationships and personal growth. However, Students with Physical Disabilities (SWPD) often face disruptions to everyday routines during their transition into and through higher education, creating a high risk for occupational imbalance.

Research Methodology and Qualitative Design

• Study Objective: To explore the lived experiences of SWPD in higher education, specifically understanding the occupational barriers they face in daily activities and the subsequent implications for occupational balance.
• Sampling and Recruitment: The study used purposive sampling to recruit participants from selected Malaysian public universities. Recruitment was conducted via official emails, meetings, phone calls, and WhatsApp. Ethical approval was obtained through the institutional review board and Disability Support Units.
• Data Collection Tool: Semi-structured interviews using guided questionnaires grounded in the ICF framework, specifically the domains of Activity and Participation.
• Interview Process:
  • Format: Online interviews via Google Meet (preferred by participants over face-to-face sessions).
  • Duration: Approximately $45-60\,\text{minutes}$.
  • Moderator: All interviews were conducted by the primary researcher, who is a qualified occupational therapist.
• Analysis Method: Thematic analysis followed Braun and Clarke’s ($2006$) six phases, utilizing NVivo software for data organization. Trustworthiness was established through verbatim transcription and collaborative analysis with a senior researcher to reduce bias.

Detailed Participant Demographics and Disability Profiles

• Total Participants ($n$): $10$ undergraduate students.
• Gender Distribution: $6$ males and $4$ females.
• Age Range: Majority between $21-24\,\text{years}$ ($n = 8$); overall range of $21-30\,\text{years}$.
• Religious Affiliation: The majority identified as Muslim, with one participant identifying as Christian.
• Disability Types:
  • Cerebral Palsy: $n = 3$
  • Amputation: $n = 2$
  • Leg length discrepancy ($left side$): $n = 1$
  • Tetra-amelia (absence of all limbs): $n = 1$
  • Lower extremity impairments: $n = 3$
• Ambulation and Assistive Aid Usage:
  • Assistive device users: $n = 3$ (including custom shoe insoles, intermittent wheelchair use, prosthetic legs, and crutches).
  • Ambulate without support: $n = 7$
• Study Levels: Participants ranged from $first year$ to $final year$ diploma and degree students.

Theme 1: Occupational Performance Challenges

• Basic Activities of Daily Living (BADL): Challenges are acute in environments lacking accessibility features.
  • Toileting: Participant P8 reported being able to squat only for a short time and shared an anecdote of falling because the floor was slippery.
  • Dressing: Participant P7 highlighted the difficulty of trying on trousers in fitting rooms without available seating.
• Instrumental Activities of Daily Living (IADL): Activities requiring high physical effort often result in dependency.
  • Meal Management: Participant P3 noted the need to depend on a sibling when carrying liquids like soup to avoid spilling due to a slow walking pace.
  • Religious Practices: Ablution and prayer were described as physically painful or inaccessible. Students often adapt by praying while seated on chairs or making early preparations.
  • Laundry: Heavy loads create balance issues. Participant P5 mentioned needing help because laundry is heavy and hard to balance.
• Education and Academic Tasks:
  • Writing: Participant P4, who writes with her foot, noted that her pace is significantly slower than peers, and long periods of writing lead to physical discomfort such as cramps.
• Leisure and Social Participation: Participation is often constrained by safety concerns or a reduced pace.
  • Mall Access: Participant P10 avoids going to malls alone because she needs to hold onto someone while walking.
  • Recreation: Participant P9 noted that when hiking, he finishes approximately $1\,\text{hour}$ later than a typical person.

Theme 2: Functional Mobility Limitations

• Walking and Environmental Obstacles:
  • Crowds: Participant P5 reported bumping into people in crowded spaces due to an inability to walk in a straight line.
  • Surfaces: Uneven pavements and drains exacerbate balance issues. Participant P3 noted that crossing uneven pavements requires a slow, step-by-step approach.
  • Fall Risk: Participant P6 expressed that even small holes in the road create a fear of tripping.
• Positional Changes and Vertical Mobility:
  • Stairs: Climbing stairs is consistently reported as hazardous. Participant P2 relies entirely on handrails to avoid falling, and Participant P1 reported feeling extreme fatigue after just one flight of stairs.
• Commuting and Public Transport:
  • Bus Usage: Struggle with long walking routes and accessing buses during peak times. Participant P5 shared that when buses are full, passengers often do not notice their disability, making it difficult to maintain balance while standing and holding handrails.

Theme 3: Functional Status Constraints

• Physical Discomfort and Health Deterioration:
  • Pain and Fatigue: Persistent pain, cramps, and fatigue limit the ability to sustain occupations. Participant P10 noted pain in the hip when using the affected left side.
  • Symptom Cascades: Participant P9 explained that excessive tiredness leads to whole-body pain, forcing the cessation of all activities for the remainder of the day.
• Interference with Academic Requirements:
  • Participant P5 detailed how sudden health issues involving leg pain, fever, and back pain directly disrupt the ability to complete work assignments.
• Impact of Secondary Health Changes:
  • Participant P8 mentioned medical advice to lose weight, as increased body mass adds pressure to the legs and further complicates mobility.

Theme 4: Limited Occupational Participation

• Dependency in Obligatory Occupations:
  • Certain essential tasks are compromised by physical limitations. Participant P4, who has an absence of limbs, must rely on others to operate ATMs, often requiring them to disclose their PIN to strangers or acquaintances.
• Restrictions in Discretionary (Leisure) Occupations:
  • Social Life: Participant P6 reported an inability to join many campus clubs or activities because they cannot move around as freely as other students.
  • Passive Engagement: Many students describe their participation in university life as "partial" or "passive" rather than full engagement due to accessibility and health barriers.

Theme 5: Occupational Deprivation and Withdrawal

• Task Avoidance for Safety:
  • Students deliberately avoid tasks perceived as unsafe. Participant P6 searches for alternative paths if a drain is too wide to cross safely.
• Disengagement from Demanding Tasks:
  • Standing: Participant P3 noted that academic presentations are often cut short because he cannot stand for long periods.
  • Domestic Withdrawal: Participant P4 reported stopping domestic tasks like laundry because it is too difficult to perform without a prosthetic leg.
• Psychosocial Consequences: Cumulative barriers lead to feelings of isolation, loss of identity, and a significant reduction in overall well-being.

Discussion and Practical Implications

• Environmental Interaction: In Malaysian universities, hilly campuses and steep pathways increase the physical and psychological burden of participation.
• Institutional Gaps: Policies in higher education often focus on structural accessibility (e.g., ramps) but frequently overlook the lived experience of daily occupations, such as the effort required for self-care or managing fatigue.
• Role of Occupational Therapy: Functional mobility is a foundational performance skill. When restricted, it diminishes participation in education, self-care, and social life. Practitioners should focus on:
  • Monitoring and addressing physical health (pain, endurance).
  • Developing compensatory strategies and adaptive techniques.
  • Empowering students to adapt and engage across academic and personal domains.
• Systemic Needs: There is a requirement for occupation-centered strategies that integrate human skill development with systemic improvements in accessibility to facilitate autonomy and independence for SWPD.

Conclusion and Recommendations

• Exhaustive Findings Summary: Barriers for SWPD extend beyond physical architecture to include performance challenges, functional status constraints, and withdrawal patterns that reshape daily routines and occupational identity.
• Study Limitations: The research is limited by a small sample size ($n=10$), focus on specific public universities, and reliance on subjective self-reporting.
• Future Research: Recommended mixed-methods studies to examine the quantitative relationship between SWPD well-being and academic success across broader, more diverse contexts.
• Core Recommendation: Universities must move beyond mere accessibility to provide holistic support that addresses individual capacities and environmental facilitators, promoting resilience and quality of life.