Abstract
A balanced pattern of occupations enhances the health and fulfills the needs of individuals, families, communities, and populations (American Occupational Therapy Association [AOTA], 2014b; Hocking, 2019; Meyer, 1922). Occupations are personalized “everyday activities that people do as individuals, in families, and with communities to occupy time and bring meaning and purpose to life” (World Federation of Occupational Therapists, 2012, para. 2). The purpose of this statement is to describe occupational therapy’s role and contribution in the areas of health promotion and prevention for internal and external audiences. AOTA supports and promotes the involvement of occupational therapy practitioners 1 in the development and delivery of programs and services that promote health, well-being, and social participation of all people.
Definitions
Well-Being
Well-being is the ultimate goal of health promotion. Well-being is an evolving concept that includes “the presence of positive emotions and moods (e.g., contentment, happiness), the absence of negative emotions (e.g., depression, anxiety), satisfaction with life, fulfillment, and positive functioning” (Centers for Disease Control and Prevention, 2018, para. 1). In occupational therapy, well-being also includes satisfaction with participation in occupations and daily activities that enhance quality of life (QoL). Eight dimensions of well-being are identified in the Substance Abuse and Mental Health Services Administration (2016) model: (1) emotional, (2) environmental, (3) financial, (4) intellectual, (5) occupational, (6) physical, (7) social, and (8) spiritual.
Health Promotion, Health, and Healthy Life
It is important to frame the discussion of occupational therapy’s role in health promotion by first defining health promotion and health. According to the Ottawa Charter for Health Promotion,
Health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental, and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector but goes beyond healthy lifestyles to well-being. (World Health Organization, 1986, para. 2, italics added)
For nearly 40 years, the U.S. Department of Health and Human Services (DHHS) has established health promotion and disease prevention objectives to facilitate and measure improvement in health (DHHS, 1980, 1990, 2000, 2010, 2018a). The vision of Healthy People 2030 is the realization of “a society in which all people achieve their full potential for health and well-being across the lifespan” (DHHS, 2018a, para. 11). Attention to all dimensions in health promotion programming is essential to facilitate overall well-being. Healthy People 2030 has five major goals:
Attain healthy, thriving lives and well-being, free of preventable disease, disability, injury, and premature death.
Eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all.
Create social, physical, and economic environments that promote attaining full potential for health and well-being for all.
Promote healthy development, healthy behaviors, and well-being across all life stages.
Engage leadership, key constituents, and the public across multiple sectors to take action and design policies that improve the health and well-being of all. (DHHS, 2018a, para. 11)
Active engagement in life and overall health status, not just longevity, are emphasized in these goals. A healthy life means the use of capacities and adaptations across the lifespan, allowing people to enter into satisfying relationships with others, to work, and to play in their community. From a national perspective, a healthy life means a person is able to be a vital, creative, and productive citizen and resident who contributes to the development of flourishing communities and a thriving nation. See Appendix A for more terms and definitions.
Strategies for Preventing the Onset and Progression of Disease and Injury
A key purpose of health promotion is improved health and well-being; quality of life; and participation for individuals, families, and populations. Health promotion, management, and maintenance for people with or without disabilities requires the implementation of prevention strategies. Prevention, generally categorized into primary, secondary, and tertiary levels, is often a collaborative interdisciplinary endeavor (Reitz et al., 2010). Individuals, groups, and populations at all levels of abilities can benefit from occupation-based strategies at each of these levels (AOTA, 2014b; Pizzi et al., 2018). Definitions and occupation-based strategies for these categories are as follows:
Primary prevention is defined as education or health promotion efforts designed to prevent the onset and reduce the incidence of unhealthy conditions, diseases, or injuries. These attempts to identify, reduce, and eliminate risk factors for disease and injury may include modifying the physical and social environment. Other strategies can include improving nutrition through family occupation-based education on meal planning and preparation; increasing physical activities through leisure education and participation; quitting smoking; managing weight; and screening for heart disease, diabetes, and cancer. All can be beneficial to individuals with existing health conditions and to the general population.
Secondary prevention strategies typically include screening, early detection (e.g., using a long-handled mirror to monitor skin integrity of the feet), and intervention after disease onset or injury has occurred. Secondary prevention involves limiting the development of secondary conditions and their subsequent impact on function and QoL (Kinne et al., 2004).
Tertiary prevention refers to services and policies designed to prevent the progression of a condition, including poverty. Strategies include promoting equal opportunity, full participation, independent living, economic self-sufficiency, advocacy, and self-advocacy (Pizzi et al., 2018).
Population Health Approach
The Triple Aim was introduced in 2008 by the Institute for Healthcare Improvement as a method not only to improve the health care experience of individuals but also to improve the health of populations, enhance patient experience, and manage costs (Berwick et al., 2008; Obucina et al., 2018). Population health focuses on aggregates, or communities of people, and the many factors that influence their health. The health of a population is the product of multiple determinants including biology and genetics, individual health behaviors, social factors, economic factors, government policies, availability and quality of health services, and physical environments. A population health approach strives to identify and reduce health disparities as well as enhance the overall health and well-being of a population (Finlayson & Edwards, 1997; Kaplan et al., 2015).
The appropriateness of occupational therapy involvement in population-based health promotion is supported by the Occupational Therapy Practice Framework: Domain and Process (AOTA, 2014b). In addition to providing occupational therapy interventions for individuals, occupational therapy practitioners develop and implement occupation-based health approaches to enhance occupational performance and participation, QoL, and occupational justice for populations. Examples of population health approaches appear later in this statement.
Role of Occupational Therapy in Health Promotion
Occupational therapy services are provided to clients (i.e., individuals, groups, and populations) of all age groups, infants through older adults, from a variety of socioeconomic, cultural, and ethnic backgrounds, who have or who are at risk for impairments, activity limitations, or participation restrictions. Occupational therapy practitioners recognize that physical and mental health is supported when clients are able to engage in occupations and activities that allow them to achieve the desired outcome of participation in their chosen environments and contexts (AOTA, 2014b, 2015b).
The essence of occupational therapy is the “belief that active engagement in occupation promotes, facilitates, supports, and maintains health and participation” (AOTA, 2014b, p. S4). Health management, including physical and mental health management and maintenance, is an important occupation for clients within the domain of occupational therapy. Health promotion and prevention are identified as occupational therapy intervention approaches, and prevention, health and wellness, QoL, participation, well-being, and occupational justice are potential outcomes of occupational therapy services (AOTA, 2014b).
Occupational therapy health promotion programs and interventions may target individuals, communities, populations, and policymakers. The focus of these efforts includes but is not limited to
Prevention or reduction in the incidence of illness or disease, accidents, and injuries in the population (e.g., through activity analysis and environmental adaptations and modifications);
Promotion of positive mental health through competence enhancement strategies, such as skill development, environmental supports, and adaptations of tasks and contexts;
Mitigation of mental illness through risk reduction strategies across the lifespan, such as establishing healthy habits and routines and providing training in relaxation and coping techniques (AOTA, 2017c);
Reduction of health disparities among racial and ethnic minority groups and other underserved populations (e.g., through advocacy and support for self-advocacy);
Enhancement of mental health, resilience, and QoL (e.g., through culturally relevant healthy occupational engagement);
Prevention of secondary conditions and improvement of the overall health and well-being of people with chronic conditions or disabilities and their caregivers (e.g., through health management training and occupational and environmental adaptation); and
Promotion of healthy living practices, social participation, occupational justice, and healthy communities, with respect for cross-cultural issues and concerns (e.g., through facilitation of culturally relevant and inclusive programming in the community).
Occupational imbalance, deprivation, and alienation are risk factors for health problems. They also may result from or lead to the development of other risk factors, which in turn can result in larger health and social problems. Causes are varied (e.g., unanticipated caregiving responsibilities, losses in employment or housing) and can lead to occupational imbalance, deprivation, and alienation, which can then lead to individual health problems such as stress, sleep disturbance, and depression (Wilcock, 2006). Addressing occupational imbalance, deprivation, and alienation can promote health and prevent further health problems.
Occupational therapy practitioners have three critical roles in health promotion and prevention that underpin these programs and interventions:
To promote healthy occupations and lifestyles for everyone, including people with various ability levels and those who are marginalized and at increased risk for health conditions;
To incorporate occupation as an essential element of health promotion strategies; and
To provide occupation-based interventions, not only with individuals but also with families, communities, and populations.
See Table1 for case examples of the role of occupational therapy in the promotion of health and well-being.
Occupational Therapy Health Promotion Case Examples
Note. AOTA = American Occupational Therapy Association; COPD = chronic obstructive pulmonary disease; COPM = Canadian Occupational Performance Measure; OT = occupational therapist; OTA = occupational therapy assistant; PFPA = Pain and Functional Performance Assessment; SAFER = Safety Assessment of Function and the Environment for Rehabilitation.
It is important that practitioners promote a healthy lifestyle for all clients, their families, and communities. Wilcock (2006) defined an approach to prevention as
the application of medical, behavioral, social, and occupational science to prevent physiological, psychological, social, and occupational illness; accidents; and disability; and to prolong quality of life for all people through advocacy and mediation and through occupation-focused programs aimed at enabling people to do, be, and become according to their natural health needs. (p. 282)
As noted previously, one goal of Healthy People 2030 is to eliminate health disparities (DHHS, 2018a). The term health disparities refers to population-specific differences in disease rates, health outcomes, and access to health care services. Populations with differing health outcomes include, but are not limited to, members of racial and ethnic minority groups (DHHS, 2019a), people with disabilities (DHHS, 2019b), and people who identify as LGBTQ+ (DHHS, 2019c). Addressing health disparities is consistent with the tenets of the occupational therapy profession. Inclusion is the acceptance and support of diversity wherein the uniqueness of beliefs, values, and attributes is welcomed, valued, and leveraged for maximum engagement (Taff & Blash, 2017).
Occupational Therapy Health Promotion Interventions
Many occupational therapy theoretical frameworks support health promotion and prevention interventions. These frameworks include the Ecology of Human Performance (Dunn et al., 1994), Person–Environment–Occupational Performance Model (Christiansen et al., 2015), and Model of Human Occupation (Kielhofner, 2002; Taylor, 2017), among others. The use of one or a combination of these models will help promote comprehensive occupation-based interventions at the individual, community, or population level.
Individuals
Occupation-based primary prevention and intervention approaches that target individuals may include
Workplace musculoskeletal injury prevention and management programs using activity and job analysis, adaptations to the work environment, and modifications to work practices;
Social and emotional skills, self-management skills, communication skills, and anger management as well as conflict resolution training for parents, teachers, and school-age youth to reduce the incidence of bullying and other violence;
Parenting skills training and family co-occupation engagement to enhance family health, promote development, and decrease stress and potential for abuse;
Fall prevention programs for community-dwelling older adults with occupation-focused home evaluations; and
Health literacy interventions to support health management and maintenance capabilities.
Examples of secondary prevention interventions may include
Education and training regarding eating habits, activity levels, and prevention of secondary disability subsequent to obesity or mobility limitations;
Education and training on how to incorporate stress management and adaptive coping strategies within daily routines to enhance resilience for children who have experienced trauma or adults with mood disorders and posttraumatic stress disorder; and
Osteoporosis management and fall prevention classes for individuals recently diagnosed with this condition.
Examples of occupation-based tertiary prevention interventions may include
Transitional or independent-living skills training for people with mental illness or cognitive impairments;
Leisure participation groups for older adults with dementia to prevent depression, enhance socialization, and improve QoL;
Social participation activities at a drop-in center for adults with severe mental illness to increase social and community engagement; and
Stroke support groups for survivors and caregivers with a focus on occupational engagement to increase occupational performance and decrease caregiver burden.
Occupational therapy practitioners work as part of an interprofessional team by adding the contribution of occupation to programs developed by experts in health education, nutrition, exercise, and so forth. For example, when working with an individual with a lower extremity amputation as a result of diabetes, the practitioner may focus on the occupation of meal preparation using foods and preparation methods recommended in the nutritionist’s health promotion program. This approach enables achievement of the occupational therapy goal of functional independence in the kitchen and reinforces the importance of proper nutrition for the prevention of further disability (Scaffa & Reitz, 2014).
Organizations, Communities, and Populations
To promote the health of a population and achieve health equity, the social determinants of health must be addressed. These determinants include economic stability, education, social and community context, health and health care, and the neighborhood and built environment (DHHS, 2018b). Social determinants of health can be addressed through collaboration with organizations and communities and through policy initiatives.
Examples of organization-level interventions may include
Providing consultation to businesses to promote well-being of workers through identification of problems and solutions for balance among work, leisure, and family life;
Providing consultation to park districts regarding implementation of Americans With Disabilities Act of 1990 (Pub. L. 101-336) requirements;
Educating day care staff to understand typical growth and development, handle behavior problems, and identify children at risk for developmental delays and obesity;
Promoting ergonomic design in workstations, such as classroom desks for students, computer stations for staff, and other work areas (e.g., custodial); and
Providing consultation to schools to increase opportunities for movement throughout the school day.
Examples of community- or population-level interventions may include
Consulting with local transportation authorities regarding accessible public transportation;
Consulting with contractors, architects, and city planners regarding accessibility and universal design;
Implementing a communitywide screening program for depression at nursing homes, assisted-living facilities, and senior centers for the purpose of developing or providing group and individual prevention and intervention programs;
Providing consultation, assessment, and intervention for chronic health conditions at a primary care facility;
Conducting needs assessments and implementing intervention strategies with other health professionals to reduce health disparities in communities with high rates of disease or injury, such as lifestyle management programs addressing hypertension, diabetes, and obesity;
Addressing the health and occupation needs of the homeless population by eliminating barriers and enhancing opportunities for occupational engagement;
Addressing the health and occupation needs of prison populations by enhancing opportunities for occupational engagement by focusing on reentry to reduce recidivism; and
Training volunteers to function effectively in special-needs shelters during disasters.
Governmental or policy-level interventions may include
Promoting policies that offer affordable, accessible health care to everyone, including people with disabilities and those from other historically marginalized backgrounds;
Promoting barrier-free environments for all ages, including aging in place and universal design;
Supporting full inclusion of children with disabilities in schools and day care programs;
Lobbying for public funds to support research and program development in areas related to improvement in QoL for people at risk and those with disabilities; and
Promoting policies that establish opportunities for recovery in the community for people with mental disorders.
Ethical Considerations
The roles of occupational therapy practitioners in evaluation and intervention in health promotion practice are based on the Guidelines for Supervision, Roles, and Responsibilities During the Delivery of Occupational Therapy Services (AOTA, 2014a). Occupational therapy practitioners have the basic knowledge and skills to carry out health promotion interventions to prevent injury and maximize well-being. However, this area of practice is broad, and practitioners must continually expand their knowledge in health promotion to be effective and competent members of a team (Reitz, 2017).
Individuals, groups, and populations are best served when community leaders, stakeholders, and a variety of health and education professionals work in interprofessional teams to provide health promotion and preventive services. Occupational therapy practitioners’ knowledge of occupations, activity analysis, and group functioning makes them essential members of such teams.
Being cognizant of and ready to address health literacy is one example of occupational therapy practitioners’ evolving knowledge base. Ensuring health literacy is a focus of national health policy and marks ethical practice across health disciplines. The Healthy People 2030 goal regarding the reduction of health disparities includes attaining health literacy as a means of improving health and well-being (DHHS, 2018a). Health literacy affects people’s ability to understand information on prescription drug bottles, participate in chronic disease self-management, follow physician recommendations, fill out complex forms, communicate with health care providers, and navigate the health care system. Therefore, health literacy is an important component of health management.
The Occupational Therapy Code of Ethics (2015) (AOTA, 2015a) establishes principles that guide safe and competent occupational therapy practice that must be applied when providing occupational therapy services. Although practitioners recognize the distinct role of occupational therapy in health promotion and prevention, it is also important for them to acknowledge and respect the contributions of other health care professions in this arena. Occupational therapy practitioners should operate within their scope of practice and training and partner with other health promotion disciplines with specialized expertise in areas such as public health, health education, nutrition, and exercise science. This professional behavior is in perfect alignment with Principle 6: Fidelity of the Code of Ethics (AOTA, 2015a).
Evidence Base for Occupational Therapy in Health Promotion
Health promotion services should be based on the best available evidence. Through AOTA’s (n.d.) Evidence-Based Resource Directory, occupational therapy practitioners can review the latest evidence-based resources for work with individuals through the lifespan as well as with families, communities, and populations. Several evidence-based occupational therapy interventions for health promotion have been developed.
A systematic review of mental health services and programming for children (Arbesman et al., 2013) found strong evidence that schoolwide antibullying programs and after-school programs are effective in improving social and emotional skills. In the same systematic review, strong evidence was reported “that childhood obesity programs affect body mass index, particularly for children aged 6–12 years” (Arbesman et al., 2013, p. 123).
An AOTA Critically Appraised Topic (CAT) found moderate evidence for the efficacy of population-based fall prevention interventions (AOTA, 2017b). This CAT provides support to occupational therapy practitioners to “consider working with interdisciplinary team members to develop population-based multicomponent fall prevention intervention programs, which include exercise to promote strength and balance, home safety education and modification, cognitive–behavioral programs, and education on fall risk factors” (AOTA, 2017b, p. 4).
Studies by Clark et al. (1997, 2001, 2012) have supported the efficacy of occupational therapy health promotion interventions in well older adults in urban communities. In a landmark study of community-dwelling older adults (the Well Elderly Study), Clark et al. (1997) evaluated the effectiveness of an occupation-based health promotion program. The intervention was found to enhance physical and mental health, occupational functioning, and life satisfaction compared with a social activities program and a no-treatment control group.
Clark et al. (2001) demonstrated a long-term benefit attributable to preventive occupational therapy when they reevaluated participants from Clark et al.’s (1997) Well Elderly Study and found that 90% of therapeutic gain observed after intervention was retained at the 6-month follow-up. In addition, the Well Elderly Study was replicated through the Well Elderly 2 trial (Clark et al., 2012) with participants from a wider array of economic and ethnic backgrounds. Occupational therapy health promotion was found to be a cost-effective method to enhance health and well-being among older adults in an urban context (Clark et al., 2012).
Research by Suarez-Balcazar et al. (2016) examined the benefits of a healthy lifestyle program for Latino youth with disabilities at risk for obesity and their families. The assessment of the culturally tailored program indicated improvements in family routines and health habits. A participatory action research project by Schmelzer and Leto (2018) resulted in the development of an occupation-based program promoting food resource management for low-income families. Statistically significant improvements after intervention included increased satisfaction and improved performance of activities involving management of available food resources, resulting in decreased food insecurity.
Summary
Exercising the power of occupation can help prevent harmful health and social conditions and promote well-being. Occupational therapy practitioners have the capacity and knowledge to positively affect the health and well-being of individuals, families, communities, and populations at local, national, and global levels. Occupation-based health promotion services can facilitate the achievement of national goals outlined in Healthy People 2030 and the fulfillment of the Triple Aim. Developing and implementing occupation-based violence prevention programs, ensuring playground accessibility, providing sleep hygiene programs, advocating for marginalized populations, and participating in sustainability initiatives are just a few examples of roles that practitioners can play to positively affect health and well-being. This area of practice is primed for further development, and future innovative health promotion solutions will be maximized through interdisciplinary collaborations.
Footnotes
Glossary of Health Promotion Terms
1
When the term occupational therapy practitioner is used in this document, it refers to both occupational therapists and occupational therapy assistants (AOTA, 2019). Occupational therapists are responsible for all aspects of occupational therapy service delivery and are accountable for the safety and effectiveness of the occupational therapy service delivery process. Occupational therapy assistants deliver occupational therapy services under the supervision of and in partnership with an occupational therapist (AOTA, 2014a).
S. Maggie Reitz, PhD, OTR/L, FAOTA
Marjorie E. Scaffa, PhD, OTR/L, FAOTA
for
The Commission on Practice
Julie Dorsey, OTD, OTR/L, CEAS, FAOTA, Chairperson
Revised by the Commission on Practice, 2019
Adopted by the Representative Assembly Coordinating Council (RACC) for the Representative Assembly, 2019
