Abstract
Since the inception of the profession of occupational therapy a century ago, a clarion call to link health with occupation and occupational engagement has been heard. For decades, leaders in the profession have emphasized the need for prevention and health promotion as well as for development of assessments and models linking health with occupation. This article addresses the need for an increased presence of occupational therapy in health and wellness, emphasizing participation over performance, to optimize the health, well-being, and quality of life of individuals, communities, and populations.
Michael A. Pizzi, PhD, OTR/L, FAOTA
Lorie Gage Richards, PhD, OTR/L, FAHA
We are a profession possessing knowledge that is particularly necessary to maintain the health of people. To move from therapist to health agent demands us to change but to change in a forward, positive way. We do not have to give up what we know, rather, we must instead be willing to know more. (Finn, 1972, p. 66)
When I (Michael A. Pizzi) worked in hospice care in the early 1980s, I recognized that a transformation of the client's being was not so much in occupational performance as in the client's participation and his or her health, well-being, and quality of life (QOL). These factors were directly related to what clients were doing, the quality of their engagement, and their ability to participate in meaningful occupation while being actively engaged in living. Despite my clients’ declining health status, occupational participation (not performance), combined with creation of a positive, supportive, and compassionate environment, helped facilitate QOL and well-being (Pizzi, 2010).
The key to best practice that promotes health, well-being, and QOL is to provide the most significant opportunity for productive and powerful engagement in occupation that is meaningful to the client’s own life (Pizzi, 2015b). Occupational therapy must substantially continue to lead the charge in validating direct links between occupation and the prevention of illness, disease, and disability and between occupation and health, well-being, and QOL if the profession is to be a leader in health care as it aspires to be.
Linking Health and Occupation
Adolph Meyer (1922), one of the profession’s founders, stated,
Our conception of man is that of an organism that maintains and balances itself in the world of reality and actuality by being in active life and active use. . . . It is the use that we make of ourselves that gives the ultimate stamp to our every organ. (p. 1)
Thus, Meyer observed that health and well-being are related to being useful (productivity), which in turn enlivens or enables humans to engage in the world (mental, physical, social, and spiritual health). According to the Ottawa Charter for Health Promotion,
Health is created and lived by people within the settings of their everyday life; where they work, learn, play and love. . . . Health is created by caring for oneself and others, by being able to make decisions and have control over one’s life circumstances. (World Health Organization [WHO], 1986, p. 4)
This statement reflects a clear link among occupation, health, and the environment.
Decades ago, occupational therapy visionaries argued for the need to create opportunities and conditions in which well-being can be realized for all people. These leaders called for occupational therapists to develop new roles in the area of wellness and health promotion (Finn, 1972; West, 1968, 1969; Wiemer, 1972), to be more closely linked with health versus medical services (West, 1968), and to view humans as their own health change agents (Finn, 1972) who, when engaged using mind, body, and spirit, can influence their own health (Reilly, 1962). These visionaries stressed that it was important for the profession to become more involved in promoting health and wellness through occupation. Yet, the health care system presented significant barriers to occupational therapists' realization of this vision.
At this time, because of the evolving health system in the United States, the occupational therapy profession now has profound opportunities to make a commitment to focus on promoting health, well-being, and QOL. To establish strong intervention and prevention programs, develop a strong evidence base, and be a leader in health care, the profession needs assessments and models that clearly link occupation and participation with health, well-being, and QOL for individuals, communities, and populations. Models that currently are the foundation for practice use occupational performance as the desired outcome. We suggest that it is essential to establish a different paradigm and, accordingly, develop models based on well-being and QOL, which are among the target outcomes identified in the Occupational Therapy Practice Framework: Domain and Process (American Occupational Therapy Association [AOTA], 2014). It is also time to closely examine the distinction between performance and participation. Participation is a much more inclusive term, one that offers less opportunity for judgment about performance by oneself or others. Participation, which subsumes performance, is what promotes health, well-being, and QOL.
The Framework states that QOL and well-being are outcomes of the occupational therapy process (AOTA, 2014, p. S35), and occupational therapy practitioners consider activity and participation to have a clear link to health (AOTA, 2013). Yet, little evidence supports this linkage. This lack of evidence is problematic because expert-centered opinion is not sufficient in today’s climate of evidence-based practice; instead, it is vital that we occupational therapy practitioners be able to provide strong evidence that occupational participation is strongly linked to health and QOL in those we serve. It is critical that we occupational therapy researchers and practitioners evaluate and document health and QOL from the client’s perspective. The client’s perspective is critical because QOL is highly individualistic; only the client, from his or her own experiences, can determine whether QOL and well-being have been achieved.
The articles in this special issue make a strong case with solid empirical evidence that occupational therapy promotes health, well-being, and QOL. They build on the evidence base already established and emphasize the need for more evidence. However, they also strongly make the case for identity transformation in the wake of societal needs. Although rehabilitation has been the profession’s main focus and identity, it behooves occupational therapy practitioners to engage in a major paradigm shift and transition from defining themselves as rehabilitation specialists to defining themselves as specialists in QOL, health promotion, and well-being who use occupation to facilitate healthy living and participation. Fervent advocacy for policies that would cover occupational therapy in prevention and health promotion services is required to stay relevant in this ever-changing health care system.
Yet, despite illustrative research presented in this issue, limited models and few assessments directly link occupation to health and well-being. The following sections describe one assessment tool and one model that make that connection explicit.
Assessment for Health, Well-Being, and Quality of Life
The Pizzi Health and Wellness Assessment (PHWA; Pizzi, 2015a), originally the Pizzi Holistic Wellness Assessment (Pizzi, 2001), was developed for adults age 18 and older and is the first valid and reliable occupation-focused and client-centered assessment tool directly linking occupational participation to health. The PHWA elicits the health and well-being perceptions of clients related to their self-defined occupational status, thus immediately including clients in the occupational therapy process as described in the Framework. The client and therapist work collaboratively on strategies the client identifies as having potential to improve QOL and well-being and that are health promoting for each area and problem-solve the management of occupational issues that are directly affected by health in six different categories.
The PHWA is not focused on disability but instead emphasizes the client’s perceived abilities and current levels of well-being and health related to performance of daily occupations. Unlike other assessments, it also focuses on client readiness for health behavior change, making the assessment much more client oriented (Pizzi, 2017b). As stated in the Ottawa Charter, “To reach a state of complete physical, mental, and social wellbeing, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment” (WHO, 1986, p. 1).
Wellness is defined in the Framework as “an active process through which individuals become aware of and make choices toward a more successful existence” (Hettler, as quoted in AOTA, 2014, p. S34). Through the assessment process, development of client-centered goals, and implementation of a collaboratively designed plan, the client begins to immediately recognize how health influences daily life engagement and productivity. The assessment allows for the discovery of the relationship between health and occupation, and practitioners can then work as change agents to facilitate not just improved occupational participation but also health, well-being, and QOL.
Unlike tools such as the Canadian Occupational Performance Measure (Law et al., 2005; see also Pollock, 1993), which focus on occupational performance, the PHWA directly relates participation in client-determined meaningful daily occupations to the client’s health status, increasing occupational therapy practitioners’ awareness that doing is not the only important aspect of living. It is also vital for practitioners to attend to the client’s health and well-being, including the being, becoming, and belonging aspects of occupation (Wilcock, 2015). This awareness creates an opportunity for the practitioner and client to collaborate on preventive occupations, not just on remediation of problems (Pizzi, 2015a).
The PHWA provides direct feedback to clients on their own perceptions of health relative to occupational participation, includes them in their own intervention process, and gives them visual feedback on how they view themselves improving their own health facilitated by an occupational therapy practitioner. Most people value being healthy and living a healthy lifestyle. When we practitioners can make correlations for people about how participation improves health, we have the potential to transform lives, to alter how people perceive and engage in occupation, and to better promote the profession as one that is committed to health, well-being, and QOL for all. This assessment is supported by the health, occupation, wellness, and QOL paradigm.
All of the current models used in occupational therapy that are foundational to assessment and intervention emphasize the importance of occupational performance as the outcome, with little attention paid to the health and well-being of individuals, communities, and populations as the ultimate outcome of service delivery. If occupational therapy is to remain current and relevant in this ever-changing health care system, it is imperative that we practitioners do better and focus on these important issues—QOL and well-being—that matter to all human beings. For example, if the occupational therapy process focuses on occupational performance as the outcome in rehabilitation, and after discharge clients fail to follow through, how can occupational therapy claim to have best served those clients? If, however, the occupational therapy process focuses on ways to improve clients’ well-being and overall QOL while working on new skills, is it possible that these new skills are more likely to remain attached to clients’ ways of maintaining and improving their health, well-being, and QOL. We must, as a profession, develop a focus on well-being and QOL as outcomes.
E–HOW Model
The Environment–Health–Occupation–Well-Being (E–HOW) Model (Pizzi, 2017a) is a practice model that provides a framework for practitioners to more easily guide practice that focuses on well-being and QOL as the outcome. The E–HOW Model is based on the following major assumptions:
Individuals, communities, and populations strive to optimize their health, well-being, and QOL.
Health, environments, and occupational performance have a dynamic influence on QOL and well-being.
Health behavior change can occur when clients become aware of a need for such change.
Participation in daily activities that are meaningful promotes a positive health trajectory for daily living.
Health is a resource used daily to pursue and participate in important and meaningful activity in life (WHO, 1986).
Use of time for an individual, community, or population in meaningful, culturally relevant, and socially appropriate daily activities can be health promoting.
Interprofessional collaboration facilitates clients’ health, well-being, and QOL.
In the E–HOW Model, health is defined as an ever-evolving and fluctuating state of physical, mental, social, and spiritual well-being that affects and is affected by environmental and occupational influences (Figure 1). Environments include the physical, social, and cultural contexts in which one participates. The practitioner–client interaction and the level of client-centeredness of that interaction are considered part of the social environment that can influence clients’ well-being and QOL. Occupational participation incorporates the occupations in which clients engage, occupational demands, routines, skills, and occupational performance. The interaction of these factors influences the level of QOL and well-being experienced by the individual, community, or population being served. Working from a dynamic systems perspective, an imbalance in any area demands a shift or a rebalancing of those factors through occupational interventions to promote improved QOL and well-being, which are defined by the client.
Environment–Health–Occupation–Well-Being (E–HOW) Model.
Implications for Occupational Therapy
Throughout this editorial, we have called for a paradigm shift to focus on QOL and well-being as the primary outcomes of occupational therapy services for individuals, communities, and populations. Although barriers and constraints on implementing this proposed paradigm exist, they must not deter occupational therapy practitioners from working toward a better future for the profession, for clients, and for society. Implications of this paradigm shift for the profession include the following:
The promotion of health, well-being, and QOL can and should be included in every client’s intervention plan to firmly establish the role of occupational therapy in health care.
A focus on health, and not only on occupational performance and participation, is imperative to move the profession forward.
Having a health focus includes addressing the physical, social, mental and emotional, and cultural aspects of doing, being, becoming, and belonging, which facilitates QOL and well-being.
A paradigm shift in occupational therapy academic institutions and in practice is mandated to carry forward the vision of promoting health, well-being, and QOL.
An expansive opportunity exists for occupational therapy research focused on health, well-being, and QOL to help meet societal needs.
Having both a model and assessments linking health and occupational participation directly, practitioners can begin to substantiate Vision 2025 for occupational therapy, which states, “Occupational therapy maximizes health, well-being, and quality of life for all people, populations, and communities through effective solutions that facilitate participation in everyday living” (AOTA, 2017, p. 1).
Conclusion
Creating links among occupation, occupational participation, and health in ways that are understandable to the general public, other health professionals, policymakers, and society must be occupational therapy’s mission. The profession must continue to strategize how occupational therapy becomes the leader, and not the follower, in the promotion of health, well-being, and QOL. There must also be a shift from performance to participation in daily life, with evidence supporting the link between participation and a person's health status. A paradigm shift is imperative to reorganize the profession and make a dramatic, if not revolutionary, shift.
More than 3 decades ago, Kielhofner (1983) wrote about a paradigm change related to occupation:
Occupational therapy has not merely added knowledge to its stockpile over the past decades, but has undergone profound shifts in its most fundamental orientations and in its clinical technologies. . . . Such a paradigm must recommit itself to the early principles of the paradigm of occupation. (p. 46)
The paradigm shift toward occupation has finally been realized. Occupational therapy must now create the paradigm of occupation as related to health, well-being, and QOL, concepts that were also noted by the founders of the profession. If occupational therapy does not focus on these concepts, other professions will happily do so.