1. The development of Activity Card Sort-United Kingdom (ACS-UK)
Alison Laver-Fawcett PhD, OT(C), DipCOT, PCAP
Sarah Mallinson, BSc, MSc
June 2014
Thank you for the opportunity to share with you today our research to develop a United Kingdom version of the Activity Card Sort which I will refer to as the ACS-UK
This study was conducted from September
This was the first project of a series of studies to standardise the ACS-UK and examine validity, reliability and clinical utility of the measure.

2. Background: Activity Card Sort (ACS)
Well established measure of activity engagement for older people (Baum and Edwards, 2008). Originally developed by Dr Carolyn Baum for use with people with dementia in the USA (Baum, 1993)
89 Photograph cards for activities grouped in 4 categories:
Instrumental, Low Demand leisure, High Demand Leisure, Social
3 ACS versions: Recovery, Institutional and Community Living (using the same photo activity cards)
Different sorting categories of engagement for the three versions
The Activity Card Sort (ACS; Baum & Edwards, 2008) is recognised internationally as a useful self-report measure of participation for clinical practice and research (e.g., Eriksson, et al., 2011)
The Activity Card Sort (ACS; Baum & Edwards, 2008) ) is a well established measure of activity engagement for older people. It is recognised internationally as a useful self-report measure of participation for clinical practice and research (e.g., Eriksson, et al., 2011)
It was originally developed by Dr Carolyn Baum, from Washington University School of Medicine in St Louis for use with people with dementia in the USA (Baum, 1993). I first came across the ACS when I was a post-doctoral fellow there in 1993.
It is now published in a 2nd edition by Carolyn Baum and Dorothy Edwards (2008).
There are 89 Photograph cards for activities grouped in 4 categories:
Instrumental, Low Demand leisure, High Demand Leisure, Social Activities
3 ACS versions:
Recovery (e.g. with people with Stroke)
Institutional (e.g. people with dementia moving into a long-term care setting)
Community Living (e.g. for older people experiencing transitions such as retirement of a care-giver role)
Regardless of the version the same 89 photo activity cards are sorted however there are different sorting categories of engagement for the three versions
In all three ACS forms, individuals are asked to identify the five activities they consider most important as a guide for intervention (Baum and Edwards, 2001).
A score to reflect the percentage of activity retained in older age / following illness can further be calculated by dividing the current activity total by a total accounting for previous activity.

3. The ACS uses Q-Sort Methodology
The ACS employs a Q-Sort methodology.
The Q-Sort methodology was originally described by Stephenson (1936 as cited in Block, 1961, p. 12) for collecting subjective data and involved the sorting of statements which were printed separately on cards to allow for ordering by subjects depending on their individual perspective.
The ACS comprises photographs on older people engaging in activities in addition to written activity labels.
According to Law, Baum and Dunn (2001) and Baum and Edwards (2001) Sorting photographs is desirable because;
it enables individuals with lower literacy levels to conduct the sort
prompts recall of activity engagement to help build a client’s occupational profile
In addition I have found it supports the development of rapport and also facilitates reminiscence related to activity engagement
The ACS uses Q-Sort Methodology
(Stephenson, 1936)

4. Other versions of the ACS
Researchers have adapted the ACS to develop culturally sensitive and valid versions:
Arab countries (A-ACS; Hamed et al., 2011; Hamed & Holm, 2013)
Australia (ACS-Australia; Packer, et al., 2008)
Hong-Kong (ACS-HK; Chan et al., 2006)
Israel (Katz et al., 2003; Sachs & Josman, 2003)
Korea (Lee, 2009, as cited in Eriksson et al., 2011)
Puerto Rico (Orellano, 2008)
Netherlands (Jong, van Nes, Lindeboom, 2012)
Singapore (as reported by Eriksson et al, 2011)
Cross-cultural research has demonstrated that the ACS has improved validity and utility when the activities depicted are relevant to people’s culture and environment (For example, Chan, Chung & Packer, 2006; Doney & Packer, 2008; Eriksson et al., 2011; Katz, Karpin, Lak, Furman, & Hartman-Maeir, 2003)
In 2008 and 2009, I supervised a group of 3rd year OT students on a dissertation project (Laver-Fawcett, 2012), this involved the administration of the ACS to explore the participation of older people with dementia and their care-givers.
Findings indicated that the ACS was an effective measure of participation with these groups, however, a number of the ACS photographs depicting activities and some activity labels proved problematic for cultural reasons (Laver-Fawcett, 2012).
A major concern related to semantics as American English is used for the wording of ACS activity descriptions and several terms used appear uncommon in the UK.
For example: ‘Taking out the trash’ (the usual UK term is ‘putting out the rubbish’); ‘Yard maintenance’ (instead of ‘gardening’); and ‘Getting gas’ (rather than ‘going to get petrol / diesel’).
The content of some ACS photographs depict activities less usual in the UK, such as baseball (football, cricket or rugby are more common sports).
Some background environments were clearly American and cars showed the driver on the left-hand side whereas in the UK cars are right-hand drive (Laver-Fawcett, 2012).

5. ACS-UK study: Purpose
To conduct a content validity study to generate and select culturally relevant activity items for inclusion in the ACS-UK.
Cross-cultural research can provide valuable findings but culturally relevant measures which maintain equivalence are needed for this purpose (Alegria, et al., 2004)
The challenge for test developers is ‘striking a balance between the emic perspective (seeking equivalence within the culture) and the etic perspective (maintaining comparability)’ (Alegria et al., 2004)
The methods used to develop other ACS culturally relevant versions were reviewed to inform this study’s methodology.
We aimed to produce a measure that included activities culturally relevant to UK older people and that replicated the ACS’ Q-sort, sorting categories and scoring method.
This study was undertaken with permission and advice on the methodology from the authors of the ACS (Baum & Edwards, 2008).
So the purpose of our research was to conduct a content validity study to generate and select culturally relevant activity items for inclusion in the ACS-UK.
Cross-cultural research can provide valuable findings but culturally relevant measures which maintain equivalence across measures are needed for this purpose (Alegria, et al., 2004)
The challenge for test developers is ‘striking a balance between what Alergria et al (2004) call the ‘emic perspective ‘ this relates to ‘seeking equivalence within the culture’ and the ‘etic perspective ‘ which relates to ‘maintaining comparability’ between measures that are developed to be equivalent (Alegria et al., 2004)
The methods used to develop other ACS culturally relevant versions were reviewed to inform this study’s methodology.
This study was undertaken with permission and advice on the methodology from the authors of the ACS (Baum & Edwards, 2008).
We aimed to produce a measure that included activities culturally relevant to UK older people and that replicated the ACS’ Q-sort, sorting categories and scoring method.

6. Item selection and reduction
ACS-UK: Mixed Method
Item generation
Item selection and reduction
Activities were drawn from the most empirically robust published versions of the ACS (in English)
(Australia, Packer et al., 2008; Hong-Kong, Chan et al., 2006; Israel, Katz et al., 2003; and US, Baum & Edwards, 2001; 2008)
Literature search of peer-reviewed research published in the last decade identified three UK time-use studies involving samples of UK older people
(Ball, Corr, Knight, & Lowis, 2007; Chilvers, Corr, & Singlehurst, 2010; Knight et al., 2007)
Expert Opinion
Ethical approval provided by the York St John University Ethics committee
Consulting a sample of people aged 65 years and over to determine the most common activities for this age group in the UK.
A survey-based design
Two-round mixed-method approach.
Round 1 comprised an activity participation questionnaire (postal or on-line survey): n = 177
Round 2 involved a further activity participation questionnaire completed either individually (postal or via interview) or in small focus groups: n = 21
The study had two phases: item generation and item selection and reduction.
Firstly Activities were drawn from the most empirically robust published versions of the ACS that were published by 2010 in English. This included 4 versions of the ACS listed on this slide.
Then a in-depth Literature search of peer-reviewed research published within the previous decade was undertaken to identify time use studies for older people in the UK. Only three UK time-use studies fitted the search inclusion criteria - references listed on this slide
Expert Opinion: was then provided by two OTs experienced in working with older people who reviewed the combined activity list and suggested improvements to wording and additional activities used in their interventions with this client group
For the item selection and reduction phase we consulted with older people resident in the UK using a mixed-method 2 round survey design. I will explain this further in a minute.
Ethical approval provided by the York St John University Ethics committee.

7. Sampling Inclusion criteria for both Rounds 1 and 2 were:
people aged 65 years or older
Living in the community
Able to communicate in English
Activity levels not restricted by illness or disability
Individuals were excluded if they were receiving care from social or national health services (other than routine general practitioner care, e.g., annual flu vaccination).
Participant recruitment was sought from all four countries and intended to reflect UK census data regarding ethnicity (Office for National Statistics, 2001)
Sampling:
convenience sampling through personal and professional contacts
purposive sampling using website-advertised older people groups
snowball sampling
This slide shows the inclusion and exclusion criteria used for participants in Round 1 and 2
The biggest challenge was to obtain a sample of ‘healthy’ older people for our study that represented the UK older population.
Healthy: was defined in two ways:
First participants considered that their activity levels were not restricted by illness or disability.
Second: individual were not receiving either social or health care, other than for routine care – such as older people health check ups or routine vaccinations.
We needed to sample people from across the four countries that make up the UK (England, Wales, Scotland and Northern Ireland). We used census data to guide our sampling.
This was a challenge so we combined convenience, purposive and snowball sampling methods
The desired sample size was established through review of previous ACS development studies and was set at 150 people.
Eriksson et al. (2011) reviewed studies related to eight ACS versions and reported sample sizes of well elderly ranging from 60 to 100 participants.
Combined total of N = 196 older people contributed to the development of the ACS-UK

8. ACS-UK: 1st Round survey
Pilot survey (n = 5; convenience sample)
Round 1 Survey (n = 177)
1 question related to inclusion / exclusion criteria
4 Consent questions
125 activity items to assess level of activity participation over the past year rated on a 5-point ordinal scale:
at least once a day
at least once a week
at least once a month
at least once a year
never
Participants were asked to suggest and rate their participation in up to five additional activities
Demographic questions: gender, marital status, age, place of birth, length of residence in UK, current place of residence to nearest town / city, highest level of education, whether retired, how long retired, if working type of work, ethnic origin.
Option of postal survey or on-line version
We conducted a pilot survey with a convenience sample of 5 older people spread across 4 English Counties (2 men and 3 women)
Round 1 involved a questionnaire administered via post or on-line.
1 question related to inclusion / exclusion criteria
4 Consent questions
125 activity items to assess level of activity participation over the past year rated on a 5-point ordinal scale:
5 = at least once a day
4 = at least once a week
3 = at least once a month
2 = at least once a year
1 = never
Participants were asked to suggest and rate their participation in up to five additional activities
Demographic questions: gender, marital status, age, place of birth, length of residence in UK, current place of residence to nearest town / city, highest level of education, whether retired, how long retired, if working type of work, ethnic origin.
Round 1 involved a questionnaire administered via post or on-line. This resulted in 177 completed questionnaires. This exceeded our minimum sample size and is the largest sample size for an ACS development study to date. While developing the A-ACS, Hamed et al. (2011) recruited 156 Jordanians from different age groups.

9. ACS-UK study: Round 2
Round 2 involved a further questionnaire: this time participants contributed to the study through a combination of interview, small group focus groups or via post (n = 21)
to consider the additional activities provided by respondents in Round 1 and establish if these 20 new activities would be relevant to the wider UK older population Perceived participation was rated on a 5-point ordinal scale: (0 = no-one does this activity to 4 = most people do this activity)
to review activity items from Round 1 that fell close to the cut-off level
to review the wording of activity items to ensure clarity
to consider the domain categorisation of activities.
The same inclusion criteria, consent questions and demographic questions were used as in Round 1.
The round 2 study was conducted for 4 purposes:
to consider the additional activities provided by respondents in Round 1 and establish if these 20 new activities would be relevant to the wider UK older population Perceived participation was rated on a 5-point ordinal scale: (0 = no-one does this activity to 4 = most people do this activity)
to review activity items from Round 1 that fell close to the cut-off level
to review the wording of activity items to ensure clarity
to consider the domain categorisation of activities.
The same inclusion criteria, consent questions and demographic questions were used as in Round 1. Round 2 involved a further questionnaire – this time participants contributed to the study through a combination of interview, small group focus groups or via post.
21 people contributed to the round 2 study. This is comparable with some other ACS studies, for example:
Chan, Chung, and Packer (2006) used a panel comprising a convenience sample of 15 community-dwelling older adults to evaluate “whether the activities on the comprehensive list reflected those in which Hong Kong older adults typically participate” (p. 154).

10. Results from Round 2 Rewording items
Encompass several items under a broader heading:
‘Paying household bills’ is an element of ‘Managing Financial matters’
‘Walking the dog’ is an aspect of ‘Taking care of pets’
Combining items:
‘Listening to radio / music’; ‘Maintaining the garden / tending your allotment’; ‘Going on holiday / travelling’; and ‘Researching family / local history’
Separating items:
‘Gambling’ (which included playing the lottery, bingo, placing a bet, and going to a casino) was expanded to form two separate items: ‘Gambling’ and ‘Playing Bingo’.
During Round 2 a number of activities were identified that either needed rewording or participants thought could be combined with other activities to reduce the number of items
Participants suggested some items that could be encompassed under broader headings, for example: ‘Paying household bills’ is an element of ‘Managing Financial matters’; ‘Walking the dog’ is an aspect of ‘Taking care of pets’
Participants advised several items could be combined, for example: ‘listening to radio / music’; ‘Maintaining the garden / tending your allotment’; ‘Going on holiday / travelling’; and ‘Researching family / local history’
In one case an item ‘Gambling’ (which included playing the lottery, bingo, placing a bet, and going to a casino) was considered too broad and was expanded to form two separate items: ‘Gambling’ and ‘Playing Bingo’.

11. ACS-UK: Data analysis & Findings
Means and standard deviations were calculated for all items:
The most common activities that UK older people had participated in over the past year (at end of Round 1)
The most common activities perceived for UK older people (at end of Round 2)
Activity items with mean values of < 2.0 were considered for removal. This was the equivalent of:
participating ‘less than once a year or never’ in Round 1
‘Rare or no participation’ in Round 2
Tables drawn up: activities ranked above this cut-off point at the end of Rounds 1 and 2 (Laver-Fawcett and Mallinson, 2013)
Means and standard deviations were calculated for all items:
The most common activities that UK older people had participated in over the past year (at end of Round 1)
The most common activities perceived for UK older people (at end of Round 2)
Activity items with mean values of < 2.0 were considered for removal. This was the equivalent of:
participating ‘less than once a year or never’ in Round 1
‘Rare or no participation’ in Round 2
Tables drawn up: activities ranked above this cut-off point at the end of Rounds 1 and 2 (Laver-Fawcett and Mallinson, 2013)
Where activities could be eliminated in one round and not the other, item standard deviations were reviewed to consider variance, focus group transcripts were consulted and the authors considered societal trends which may impact older people’s activities in future. For example, working in paid employment was included in the ACS-UK because of planned increases in retirement age for UK employees (The Pensions Act 2011).
Fishing was included because Round 2 participants indicated it was salient to the older UK male population; as both samples contained a higher proportion of female participants there was a possibility data might not have adequately represented a male perspective.
The item ‘Dating / companion seeking’ was included owing to research that projects a significant increase in internet-based social networking amongst adults (Stroud, 2008).

12. Activity Card Sort – United Kingdom (ACS-UK)
91 Activity items were grouped under four categories:
instrumental activities of daily living (n = 27)
high demand leisure activities (n = 15)
low demand leisure activities (n = 25)
and social / cultural activities (n = 24)
We ended up with 91 activities for inclusion in the ACS-UK.
We used the same 4 domains as the ACS (2nd edition) however the fourth category has been called social and cultural activities – following the focus group discussion.
The instrumental activities of daily living category has the largest number of activity items (n = 27)
Whilst the high demand leisure activities category contains the smallest number of activities (n = 15)
low demand leisure activities (n = 25)
and social / cultural activities (n = 24)

13. Sorting categories for ACS-UK
Recovery version (Form B)
Not Done
Before
Current
Illness or
Injury
Continued to
Do During
Illness or
Injury
Doing Less
Since Illness or
Injury
Given Up Due
to Illness or
Injury
New Activity
Since Illness
or Injury
Community-Living version (Form C)
Not done in past year
Not done since age 60
Do Now
Do Less
Given Up
Done
Previously
In our previous study using the ACS (2nd edition, Baum and Edwards, 2008) Community Living version with people with dementia and their carers the sorting ‘not done since age 60’ proved to be difficult for participants to sort.
The version from the Netherlands found not done since age 60 problematic and their version anchors the sort against – not done in the past year. So we have decided to also use this in place of ‘not done since age 60’ card.
We have also added a ‘Do more’ category, but because our research fund that ‘doing more’ can be perceived as both a negative or a positive change depending on the activity and the perspective of the person this is added only to provide further qualitative information and is not scored. Therefore are scoring method is comparable to that used for the ACS
Institutional version (Form A)
Do More
Done prior to illness / injury or admission
Not done prior to illness / injury or admission
+ Identify the five most important activities to you (they may be those you no longer do)

14. ACS-UK study: Findings
The ACS-UK has seven items not included in other ACS versions
being on a committee
voting
keeping a diary / calendar of events
relaxing / meditating
attending a leisure / hobby group
going for drinks at pubs / social clubs
attending a night class / adult education group
When we compared the ACS-UK to other ACS versions we found that the ACS-UK includes 7 items not found in other versions and these seven activities are listed on this slide.
It is unlikely that these activities are unique to older people in the UK; voting, for example, should be applicable to older people in other democratic countries.
Literature on other ACS versions does not comprehensively detail activities that have not met the cut-off criteria for inclusion it is not possible to establish whether these seven ACS-UK items have been considered for inclusion in any other ACS versions.
ACS versions do not attempt to include an exhaustive number of activities, but rather activities that are the most common within a specific culture.

15. Findings
ACS (Baum & Edwards, 2008) item ‘Reading magazines / books’ was separated into two items for the ACS-UK following feedback from people with dementia (Laver-Fawcett, 2012) who found this combined activity item difficult to categorize
They explained that owing to short term memory problems they were unable to remember the plot or characters required to read books, but were still able to read magazines.
There were a number of other changes that we have made. For example,
ACS (Baum & Edwards, 2008) item ‘Reading magazines / books’ was separated into two items for the ACS-UK following feedback from people with dementia (Laver-Fawcett, 2012) who found this combined activity item difficult to categorize
They explained that owing to short term memory problems they were unable to remember the plot or characters required to read books, but were still able to read magazines.

16. Example ACS-UK activity card
Voting ACS-UK: 79
It has been a big challenge to photograph all 91 activities.
A student of photography at York St John was involved. Some participants in round 2 have provided photos.
OT students involved in clinical utility, face validity and discriminant validity studies have been involved in photographing activities.
First photographs were reviewed by occupational therapists at the Retreat Hospital
Hardest activity to photograph was Voting – as I was not allowed to take a photograph within a poling station for legal reasons.
We have written consent for the use of all photographs for the ACS-UK, manual and related presentations and publications.

17. Comparison with other ACS versions (study by Eriksson et al, 2011)
One hundred and five different ACS items were identified across eight ACS versions by Eriksson et al (2011).
10 activities were identified as ‘central activities’ for older people
All 10 central activities are included in the ACS-UK
16 activities were identified as Central Asian Activities
8/ 16 in ACS-UK, but there was some slight variation in terminology used in the ACS-UK.
18 activities identified as Central Western Activities
16/18 of theses are included in the ACS-UK and 2 other activities were considered during this study, but did not meet the cut off.
The development of culturally sensitive ACS versions is now enabling cross-cultural research.
For example, developers of 8 different versions of the ACS complied ACS data from well elderly samples (total N = 468) has enabled a cross-cultural comparison of older people’s participation (Eriksson et al., 2011) Note: this study did not include the A-ACS / ACS-UK
Eriksson et al. (2011) offer their cross cultural description as ‘a starting point for further exploration of everyday occupations among older adults’ (p. 182)
One hundred and five different ACS items were identified across eight ACS versions by Eriksson et al (2011;
10 activities were identified as ‘central activities’ for older people in these 8 versions
All 10 central activities are included in the ACS-UK
16 activities were identified as Central Asian Activities
8/ 16 in ACS-UK, but there was some slight variation in terminology used in the ACS-UK.
18 activities identified as Central Western Activities
16/18 of theses are included in the ACS-UK and 2 other activities were considered during this study, but did not meet the cut off.

18. Limitations related to the sample
More females than males (Round 1 = 72.3 % and Round 2 = 57.1% female participants)
Whilst there was some ethnic diversity:
(Round 1: 82.4% were White British; 6.3% Asian / Asian British; 1.1% White European; 10.2% White Irish)
Our sample did not include people from Chinese, Black Caribbean, Black African, or Black British ethnicities
Future studies:
samples with greater ethnic diversity
individuals experiencing health conditions
representative gender distribution
These results should be considered within the context of the study’s limitations. Participants were predominantly drawn from convenience samples and did not fully represent the 2001 census data regarding ethnicity (Office for National Statistics, 2001) because the sample did not include people from Chinese, Black Caribbean, Black African, or Black British ethnicities. Furthermore, both samples included more females than males (Round 1 = 72.3 % and Round 2 = 57.1% female participants); this might relate to the higher life expectancy of women (European Health Expectancy Monitoring Unit, 2010) and has also been an issue in another ACS development study (ACS-Australian study )
These could be viewed as limiting factors regarding generalizing the findings to a wider United Kingdom population, so future studies may want to explore activity participation and engagement in samples with greater ethnic diversity, individuals experiencing health conditions, and a representative gender distribution.
At the development phase, the psychometric properties of the ACS-UK have yet to be established. Future research should examine interrater reliability, internal consistency, test–retest reliability, discriminant validity, and face validity of the ACS-UK.

19. Key reference
Laver-Fawcett AJ, Mallinson S (2013) The Development of the Activity Card Sort – United Kingdom version (ACS-UK). OTJR: Occupation, Participation, and Health, 33 (3), DOI: /
Further details of this study can be found in the article that Sarah and I have had published in the Occupational Therapy Journal of Research last summer.
A full reference list is provided on slides at the end of this presentation and I’d be happy to these slides to colleagues on request

20. Acknowledgments
Faculty of Health and Life Sciences, York St John University: funding for a 0.2FTE research assistant for 1 year and funding to present this paper at the WFOT congress
Carolyn Baum and Dorothy Edwards: permission to develop the ACS-UK and advice on the methodology for this study
Sarah Mallinson: research assistant on this study ( )
Stephen Wey, Senior Lecturer, York St John University: facilitating a focus group for Round 2 & expert opinion for item generation
Joyce Latimer, OT at the Retreat Hospital: support recruiting round 2 participants & expert opinion for item generation
Occupational therapists at the Retreat Hospital: feedback on the quality of ACS-UK activity photographs
All the 196 participants who contributed to this study
All the people who have contributed photographs
Many people have contributed to the development of the ACS-UK so far and I have acknowledged them on this slide.

21. Questions and discussion
I would now like to invite your questions and comments
Research Centre for Occupation & Mental Health (RCOMH)

22. Contact details Alison J. Laver-Fawcett, PhD, O.T.(C), DipCOT, PCAP
Faculty of Health and Life Sciences
York St John University
Lord Mayor’s Walk, York
YO31 7EX
+44(0)

23. References
Alegria A., Vila D., Woo, M., Canino G., Takeuchi D., Vera M., Febo V., Guarnaccia P., Aguilar-Gaxiola S., & Shrout P. (2004) Cultural Relevance and Equivalence in the NLAAS Instrument: Integrating Etic and Emic in the Development of Cross-Cultural Measures for a Psychiatric Epidemiology and Services Study of Latinos. International Journal of Methods in Psychiatric Research. 13(4) 270–288. [Online] Available: [Accessed 13 March 2014]
Ball, V., Corr, S., Knight, J., & Lowis, M. (2007). An investigation into the leisure occupations of older adults. British Journal of Occupational Therapy 70,
Baum, C. M. (1993). The effects of occupation on behaviors of persons with senile dementia of the Alzheimer’s type and their careers. Dissertation, George Warren Brown School of Social Work, Washington University, St. Louis.
Baum, C. M., & Edwards, D. F. (2008). Activity Card Sort (ACS): Test manual (2nd Ed). Bethesda, MD: AOTA Press.
Block J (1961) The Q-Sort method in personality assessment and psychiatric research. Springfield: Charles C Thomas Publisher [On-line] Available: [28th March 2014].

24. References
Chan, W. K., Chung, J., & Packer, T. L. (2006). Validity and reliability of the Activity Card Sort – Hong Kong version. OTJR: Occupation, Participation, and Health, 26, 152–158.
Chilvers, R., Corr, S., & Singlehurst, H. (2010). An Investigation into the Occupational Lives of Healthy Older People through their Use of Time. Australian Occupational Therapy Journal, 57,
Doney R. M., & Packer T. L. (2008). Measuring changes in activity participation of older Australians: Validation of the Activity Card Sort–Australia. Australasian Journal on Ageing, 27, 33–37.
Eriksson, G. M., Chung, J. C. C., Beng, L. H., Hartman-Maeir, A., Yoo, E., Orellano, E. M., van Nes, F., DeJonge, D., & Baum, C. (2011). Occupations of older adults: A cross cultural description. OTJR: Occupation, Participation, and Health, 31(4)
Hamed R., AlHeresh R., Abu Dahab S., Collins B., Fryer J., & Holm M.B. (2011). The Development of Arab Heritage Activity Card Sort (A-ACS). International Journal of Rehabilitation Research 34 (4),
Hamed, R., & Holm M.B., (2013) Psychometric Properties of the Arab Heritage Activity Card Sort. Occupational Therapy International, 20,
Hartman-Maeir A, Soroker N, Ring H, Avni N, Katz N (2007) Activities, participation and satisfaction one-year post stroke. Disability Rehabilitation, 29(7):
Jong AM, van Nes FA, Lindeboom R. (2012) The Dutch Activity Card Sort institutional version was reproducible, but biased against women. Disabil Rehabil 34(18):

25. References
Kalldalen A, Marcusson J & Wressle E (2013) Interests among older people in relation to gender, function and health related quality of life. British Journal of Occupational Therapy, 76 (2),
Katz, N., Karpin, H., Lak, A., Furman, T., & Hartman-Maeir, A. (2003). Participation in occupational performance: Reliability and validity of the Activity Card Sort. OTJR: Occupation, Participation, and Health, 23, 10–17.
Laver-Fawcett, A. (2012) Activity Card Sort – Letter to the Editor. British Journal of Occupational Therapy, 75 (10) 482.
Laver-Fawcett AJ, Mallinson S (2013) The Development of the Activity Card Sort – United Kingdom version (ACS-UK). OTJR: Occupation, Participation, and Health, 33 (3), DOI: /
Law, M., Baum, C. M. & Dunn, W. (2001). Measuring occupational performance: Supporting best practice in occupational therapy. Thorofare, NJ: Slack
Orellano, E. (2008). Occupational participation of older Puerto Rican adults: Reliability and validity of a Spanish version of the Activity Card Sort. PhD Dissertation, Nova Southeastern University, Montana.
Packer, T. L., Boshoff, K., & DeJonge, D. (2008). Development of the Activity Card Sort – Australia. Australian Occupational Therapy Journal, 55, 199–206.
Packer, T., Girdler, S., Boldy, D., Dhaliwal, S., & Crowley, M. (2009). Vision self-management for older adults: a pilot study. Disability & Rehabilitation, 31,
Sachs, D. & Josman, N. (2003). The Activity Card Sort: A factor analysis. OTJR: Occupation, Participation and Health, 23,